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Crural closure, not fundoplication, results in a significant decrease in lower esophageal sphincter distensibility

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Abstract

Introduction

The esophagogastric junction (EGJ) is a complex anti-reflux barrier whose integrity relies on both the intrinsic lower esophageal sphincter (LES) and extrinsic crural diaphragm. During hiatal hernia repair, it is unclear whether the crural closure or the fundoplication is more important to restore the anti-reflux barrier. The objective of this study is to analyze changes in LES minimum diameter (Dmin) and distensibility index (DI) using the endoluminal functional lumen imaging probe (FLIP) during hiatal hernia repair.

Methods

Following implementation of a standardized operative FLIP protocol, all data were collected prospectively and entered into a quality database. This data were reviewed retrospectively for all patients undergoing hiatal hernia repair. FLIP measurements were collected prior to hernia dissection, after hernia reduction, after cruroplasty, and after fundoplication. Additionally, subjective assessment of the tightness of crural closure was rated by the primary surgeon on a scale of 1 to 5, 1 being the loosest and 5 being the tightest.

Results

Between August 2018 and February 2020, 97 hiatal hernia repairs were performed by a single surgeon. FLIP measurements collected using a 40-mL volume fill without pneumoperitoneum demonstrated a significant decrease in LES Dmin (13.84 ± 2.59 to 10.27 ± 2.09) and DI (6.81 ± 3.03 to 2.85 ± 1.23 mm2/mmHg) after crural closure (both p < 0.0001). Following fundoplication, there was a small, but also statistically significant, increase in both Dmin and DI (both p < 0.0001). Additionally, subjective assessment of crural tightness after cruroplasty correlated well with DI (r = − 0.466, p < 0.001) and all patients with a crural tightness rating ≥ 4.5 (N = 13) had a DI < 2.0 mm2/mmHg.

Conclusion

Cruroplasty results in a significant decrease in LES distensibility and may be more important than fundoplication in restoring EGJ competency. Additionally, subjective estimation of crural tightness correlates well with objective FLIP evaluation, suggesting surgeon assessment of cruroplasty is reliable.

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Authors and Affiliations

  1. Department of Surgery, Northshore University HealthSystem, 2650 Ridge Ave, GCSI Suite B665, Evanston, IL, 60201, USA

    Mikhail Attaar, Bailey Su, Harry Wong, Zachary Callahan, Kristine Kuchta, Stephen Stearns, John G. Linn, Woody Denham, Stephen P. Haggerty & Michael B. Ujiki

  2. Department of Surgery, University of Chicago, Chicago, IL, USA

    Mikhail Attaar, Bailey Su & Harry Wong

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  1. Mikhail Attaar
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Correspondence to Mikhail Attaar.

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Disclosures

Disclosure Information: Dr. Ujiki received speaker payments from Medtronic for instructional courses on the use of FLIP. Disclosures outside the scope of this work: Drs. Mikhail Attaar and Stephen P. Haggerty are supported by an institutional grant from Intuitive Foundation. Drs. John G. Linn, Stephen P. Haggerty, and Michael B. Ujiki receive payment for lectures from Gore. Dr. Michael B. Ujiki is a board member for Boston Scientific, is a paid consultant to Olympus and Cook, and receives payment for lectures from Medtronic, GORE, and Erbe. Dr. Stephen P. Haggerty received consultant and speaker fees from the renal division of Medtronic for work with peritoneal dialysis catheters and insertion techniques, development of educational materials, and serving as a lecturer and proctor for hands-on courses. Drs. Bailey Su, Harry Wong, Zachary Callahan, and Woody Denham, Ms. Kristine Kuchta, and Mr. Stephen Stearns have no conflict of interest or financial ties to disclose.

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Attaar, M., Su, B., Wong, H. et al. Crural closure, not fundoplication, results in a significant decrease in lower esophageal sphincter distensibility. Surg Endosc 36, 3893–3901 (2022). https://doi.org/10.1007/s00464-021-08706-5

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