Effect of Hiatus Hernia Repair and Truncal Vagotomy on Human Lower Esophageal Sphincter Pressures

Abstract Background Hiatus Hernia (HH), with its anatomical/physiological derangement of esophagogastric junction (EGJ) barrier function is a risk factor for pathological gastro-esophageal reflux (GER). However, a subset of patients with HH do not have reflux. The aim of this study is to explore Lower Esophageal sphincter parameters and GER across the EGJ in patients with manometeric type C hiatal hernia (LES-Crural Diaphragm separation > 1cm, and Pressure Inversion Point below LES). Methods An IRB approved, prospectively maintained esophageal testing registry was queried to identify patients who underwent High Resolution Manometry and 24h pH study (within 1 week) between 11/01/2016 and 11/01/2017. HRM characteristics of the EGJ (LES-CD separation, overall length, LESP, LESPI), 24 hour pH score, and pH < 4 holding time were extracted. Spearman's Rho correlation was calculated for all parameters and Receiver operating characteristic (ROC) curve was applied for parameters with significant correlation. Results A total of 1139 patients underwent HRM during the study period, of these 416 also had 24 hour pH study. 76 Patients met criteria for EGJ morphology Type C. After excluding patients with major disorders of peristalsis (16) the remaining 60 patients form the cohort of this study. Hiatal hernia size, overall length of LES, and LESPI did not correlate with 24 hour pH score or pH < 4 holding time. LESP had a significant negative correlation both with 24 hour pH score (R: -0.322; P = 0.011), and total acid holding time (R: -0.348; P = 0.006). A LESP cut-off value of 24.4 mmHg had a sensitivity of 53.8% and a Specificity of 91.2% for predicting pathological reflux. Conclusion A higher LESP (> 24.4 mmHg) appears to provide an effective barrier to pathological GER even when normal EGJ function is compromised by a hiatal hernia. Disclosure All authors have declared no conflicts of interest.

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Trans-Oral Incisionless Fundoplication (TIF): How I Do It and Why

Foregut: The Journal of the American Foregut Society ◽

10.1177/26345161211024935 ◽

2021 ◽

pp. 263451612110249

Author(s):

Kenneth J. Chang

Keyword(s):

Hernia Repair ◽

Lower Esophageal Sphincter ◽

Treatment Option ◽

Structure And Function ◽

Transoral Incisionless Fundoplication ◽

Standardized Protocol ◽

Esophageal Sphincter ◽

And Function ◽

Flap Valve

Transoral Incisionless Fundoplication (TIF) is designed to create a 3 cm length, 270° to 300°, omega-shaped flap valve, reconstructing the structure and function of the lower esophageal sphincter (LES), including the gastric sling fibers. As such, TIF is a treatment option for GERD patients with an intact crura, but have lost the integrity and function of the LES. In patients requiring a hernia repair, TIF can be used concomitantly (cTIF). While there are a number of steps to the TIF 2.0 procedure, many of the sequences are repetitive and follow a standardized protocol, optimizing efficiency, safety, and scalability.

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Kinetics of transient hiatus hernia during transient lower esophageal sphincter relaxations and swallows in healthy subjects

Neurogastroenterology & Motility ◽

10.1111/j.1365-2982.2012.01948.x ◽

2012 ◽

Vol 24 (11) ◽

pp. 990-e539 ◽

Cited By ~ 16

Author(s):

Y. Y. Lee ◽

J. G. H. Whiting ◽

E. V. Robertson ◽

M. H. Derakhshan ◽

A. A. Wirz ◽

...

Keyword(s):

Lower Esophageal Sphincter ◽

Hiatus Hernia ◽

Healthy Subjects ◽

Esophageal Sphincter ◽

Kinetics Of

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Esophagogastric junction distensibility: a factor contributing to sphincter incompetence

AJP Gastrointestinal and Liver Physiology ◽

10.1152/ajpgi.00279.2001 ◽

2002 ◽

Vol 282 (6) ◽

pp. G1052-G1058 ◽

Cited By ~ 96

Author(s):

John E. Pandolfino ◽

Guoxiang Shi ◽

Jennifer Curry ◽

Raymond J. Joehl ◽

James G. Brasseur ◽

...

Keyword(s):

Gastroesophageal Reflux Disease ◽

Gastroesophageal Reflux ◽

Lower Esophageal Sphincter ◽

Hiatus Hernia ◽

Reflux Disease ◽

Esophagogastric Junction ◽

Normal Subjects ◽

Opening Pressure ◽

Esophageal Sphincter

To quantify the effect of hiatus hernia (HH) on esophagogastric junction (EGJ) distensibility, eight normal subjects and nine gastroesophageal reflux disease (GERD) patients with HH were studied with concurrent manometry, fluoroscopy, and stepwise controlled barostatic distention of the EGJ. The minimal barostatic pressure required to open the EGJ during the interswallow period was determined. Thereafter, barium swallows were imaged in 5-mmHg increments of intrabag pressure. EGJ diameter and length were measured at each pressure during deglutitive relaxation. The EGJ opening diameter was greater in hernia patients compared with normal subjects during deglutitive relaxation at all pressures, and EGJ length was 23% shorter. EGJ opening pressure among hernia patients was lower than normal subjects during the interswallow period. In conclusion, the EGJ of GERD patients with HH was more distensible and shorter than normal subjects. These findings partially explain why HH patients are predisposed to reflux by mechanisms other than transient lower esophageal sphincter relaxations, sustain greater volumes of refluxate, and have a reduced ability to discriminate gas from liquid reflux.

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Response of canine lower esophageal sphincter to gastric distension

AJP Gastrointestinal and Liver Physiology ◽

10.1152/ajpgi.1990.259.3.g380 ◽

1990 ◽

Vol 259 (3) ◽

pp. G380-G385 ◽

Cited By ~ 11

Author(s):

S. J. Franzi ◽

C. J. Martin ◽

M. R. Cox ◽

J. Dent

Keyword(s):

Lower Esophageal Sphincter ◽

Gastric Wall ◽

Progressive Increase ◽

Truncal Vagotomy ◽

Gastric Distension ◽

Wall Tension ◽

Proximal Stomach ◽

Lower Esophageal Sphincter Relaxation ◽

Esophageal Sphincter ◽

Antral Distension

The aim of this study was to localize the region of the stomach responsible for triggering distension-induced transient lower esophageal sphincter relaxation (TLESR). The canine stomach was partitioned into subsegments by a row of buttressed sutures. This separated either the fundus from the lesser curve or the proximal stomach from the antrum. After 1 mo each region was progressively distended while gastroesophageal pressures were monitored. At the time of the first TLESR, gastric wall tension was estimated from the bag pressure and volume. Distension of the intact stomach, lesser curve, or proximal stomach in 12 dogs produced a progressive increase in lower esophageal sphincter (LES) pressure, which was interrupted at low gastric wall tension (29, 35, and 40 mmHg.cm, respectively) by a superimposed TLESR. Background LES pressure fell progressively with distension of the antrum but was unchanged by distension of the fundus alone. Both the fundus and antrum had significantly higher thresholds for triggering TLESR (96 and 105 mmHg.cm). In another two dogs truncal vagotomy performed at the time of gastric partitioning prevented both the change in background LES pressure, and the triggering of TLESR, associated with proximal gastric and antral distension. We conclude that the subcardiac region of the stomach is primarily responsible for triggering TLESR induced by distension and that the effect on background LES pressure depends on the region distended.

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