Endoscopic assessment of hiatal hernia repair

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Presentation transcript:

Endoscopic assessment of hiatal hernia repair David A. Johnson, MD, Ziad Younes, MD, Walter J. Hogan, MD Gastrointestinal Endoscopy Volume 52, Issue 5, Pages 650-659 (November 2000) DOI: 10.1067/mge.2000.109711 Copyright © 2000 American Society for Gastrointestinal Terms and Conditions

Fig. 1 Retroverted endoscopic view of normal-appearing Nissen fundoplication showing rugal folds parallel to each other and the markings on the endoscope. Gastrointestinal Endoscopy 2000 52, 650-659DOI: (10.1067/mge.2000.109711) Copyright © 2000 American Society for Gastrointestinal Terms and Conditions

Fig. 2 Retroverted endoscopic view of normal-appearing Belsey repair. Gastrointestinal Endoscopy 2000 52, 650-659DOI: (10.1067/mge.2000.109711) Copyright © 2000 American Society for Gastrointestinal Terms and Conditions

Fig. 3 Retroverted endoscopic view of normal-appearing Hill repair. Gastrointestinal Endoscopy 2000 52, 650-659DOI: (10.1067/mge.2000.109711) Copyright © 2000 American Society for Gastrointestinal Terms and Conditions

Fig. 4 Retroverted endoscopic view of normal-appearing Toupet repair (reprinted here with permission, courtesy of Dr. J. P. Waring). Gastrointestinal Endoscopy 2000 52, 650-659DOI: (10.1067/mge.2000.109711) Copyright © 2000 American Society for Gastrointestinal Terms and Conditions

Fig. 5 Retroverted endoscopic view of Lax Belsey fundoplication showing patulous gap between the endoscope and the gastric fundus. Gastrointestinal Endoscopy 2000 52, 650-659DOI: (10.1067/mge.2000.109711) Copyright © 2000 American Society for Gastrointestinal Terms and Conditions

Fig. 6 A, Retroverted endoscopic view of Nissen fundoplication that is too loose. B, The endoscope can be withdrawn proximally without resistance through the wrap zone. Gastrointestinal Endoscopy 2000 52, 650-659DOI: (10.1067/mge.2000.109711) Copyright © 2000 American Society for Gastrointestinal Terms and Conditions

Fig. 7 Retroverted endoscopic view of loosened Nissen fundoplication showing migration of folds (circle) into the hiatus. Gastrointestinal Endoscopy 2000 52, 650-659DOI: (10.1067/mge.2000.109711) Copyright © 2000 American Society for Gastrointestinal Terms and Conditions

Fig. 8 Retroverted endoscopic view of Nissen fundoplication with more severe laxity with more expensive unfolding of gastric rugae and (A) amorphous-appearing repair (B) patulous introitus. Both patients had relapse of severe esophagitis. Gastrointestinal Endoscopy 2000 52, 650-659DOI: (10.1067/mge.2000.109711) Copyright © 2000 American Society for Gastrointestinal Terms and Conditions

Fig. 9 Endoscopic view of displacement of the squamocolumnar junction into the tubular esophagus (>1 cm above the introitus) consistent with herniation of the stomach through the wrap zone. Gastrointestinal Endoscopy 2000 52, 650-659DOI: (10.1067/mge.2000.109711) Copyright © 2000 American Society for Gastrointestinal Terms and Conditions

Fig. 10 Slipped Nissen repair with intrathoracic migration of the fundus showing: A, Endoscopic appearance showing repair and herniation suggestive of paraesophageal diverticulum (reprinted here with permission, courtesy of Dr. R. Hinder). B, Barium esophagogram with evidence of distal obstruction. C, Chest x-ray showing intrathoracic gastric “air bubble.” Gastrointestinal Endoscopy 2000 52, 650-659DOI: (10.1067/mge.2000.109711) Copyright © 2000 American Society for Gastrointestinal Terms and Conditions

Fig. 11 A, Barium-contrast radiograph showing near total disruption of the fundoplication. B, Retroverted endoscopic view (in same patient as A) showing complete disruption of Nissen fundoplication. Note suture at 2 o'clock position. Gastrointestinal Endoscopy 2000 52, 650-659DOI: (10.1067/mge.2000.109711) Copyright © 2000 American Society for Gastrointestinal Terms and Conditions

Fig. 12 A, Endoscopic view of achalasia-like appearance of distal esophagus in a patient following a Nissen fundoplication. At preoperative manometry in this patient, there was no evidence of achalasia. B, Barium esophagogram (corresponding to A) showing significant distal esophageal narrowing. This area is nondistensible in contrast to the mid esophagus which distends readily in response to administration of effervescent granules. C, Normal-appearing retroflexed endoscopic view of fundoplication (for A). D, Endoscopic view showing blanching due to ischemia precipitated by attempted balloon dilation of the distal esophageal stenosis suggesting an inordinately tight stenosis, likely transmural process (corresponding to A). Gastrointestinal Endoscopy 2000 52, 650-659DOI: (10.1067/mge.2000.109711) Copyright © 2000 American Society for Gastrointestinal Terms and Conditions

Fig. 13 Endoscopic retroflexed view of overly tight fundoplication. This patient had dysphagia predominantly for solid food. Note the “tension like” tautness of the repair. Gastrointestinal Endoscopy 2000 52, 650-659DOI: (10.1067/mge.2000.109711) Copyright © 2000 American Society for Gastrointestinal Terms and Conditions

Fig. 14 Barium-contrast radiograph showing posterior dehiscence of fundoplication with proximal herniation. Gastrointestinal Endoscopy 2000 52, 650-659DOI: (10.1067/mge.2000.109711) Copyright © 2000 American Society for Gastrointestinal Terms and Conditions

Fig. 15 Endoscopic view of intussusception of the wrap zone into the tubular esophagus. Gastrointestinal Endoscopy 2000 52, 650-659DOI: (10.1067/mge.2000.109711) Copyright © 2000 American Society for Gastrointestinal Terms and Conditions

Fig. 16 Retroverted endoscopic view of failed Nissen fundoplication with large ulcer at the base of the paraesophageal hernia. Gastrointestinal Endoscopy 2000 52, 650-659DOI: (10.1067/mge.2000.109711) Copyright © 2000 American Society for Gastrointestinal Terms and Conditions