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Anatomy of the Reflux Barrier in Health, Disease, and Reconstruction

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Fundoplication Surgery

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Abstract

A thorough understanding of the anatomy and physiology of the components of the reflux barrier is essential to achieving success with any antireflux operation. The reflux barrier is a concept that has grown over the last century. Although there has always been an intuitive understanding of a valve-like mechanism between the esophagus and the stomach, the identification of the corresponding structures and understanding their individual role in creating a functional reflux barrier has been an ongoing effort.

As a functional unit, the reflux barrier is given the difficult task of maintaining aboral patency as well as offering a graded valve that selectively either allows for gastric venting or prevents retrograde reflux. It must perform this task between two visceral cavities with varying pressure and under constant motion. In health, a functional reflux barrier depends on the synergy of multiple components—an intact lower esophageal sphincter located within the abdominal pressure compartment, the crural diaphragm, the phrenoesophageal ligament and a functional flap valve mechanism with an intact angle of His. When one or more of these components fail, progressive pathological reflux can occur.

With this chapter, we identify the key components and contributors to the reflux barrier, describe their discovery as well as their function, and show the underlying principles that are employed during surgery to reestablish a functioning reflux barrier.

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References

  1. El-Serag HB, Sweet S, Winchester CC, Dent J. Update on the epidemiology of gastro-oesophageal reflux disease: a systematic review. Gut. 2014;63(6):871–80.

    Article  PubMed  Google Scholar 

  2. Cohen E, Bolus R, Khanna D, Hays RD, Chang L, Melmed GY, et al. GERD symptoms in the general population: prevalence and severity versus care-seeking patients. Dig Dis Sci. 2014;59(10):2488–96.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Everhart JE, Ruhl CE. Burden of digestive diseases in the United States part I: overall and upper gastrointestinal diseases. Gastroenterology. 2009;136(2):376–86.

    Article  PubMed  Google Scholar 

  4. American Gastroenterological Association. The burden of gastrointestinal diseases. Bethesda: American Gastroenterological Association; 2001.

    Google Scholar 

  5. Jackson C. The diaphragmatic pinchcock in so call “cardiospasm”. Laryngoscope. 1922;32:132.

    Google Scholar 

  6. Forssell G. Studies of the mechanism of movement of the mucos membrane of the Digestive Tract.pdf. Am J Roentgenol. 1923;10(2):87–104.

    Google Scholar 

  7. Payne W, Poulton EP. Experiments on visceral sensation. J Physiol. 1927;63:217.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  8. Code CF, Fyke FE, Schlegel JF. The gastroesophageal sphincter in healthy human beings. Gastroenterologia. 1956;86(3):135–50.

    Article  CAS  PubMed  Google Scholar 

  9. Vantrappen G, Texter EC, Barborka CJ, Vanden-Broucke J. The closing mechanism at the gastroesophageal junction. Am J Med. 1960;28:564–77.

    Article  CAS  PubMed  Google Scholar 

  10. Sinnhuber. Beitraege zur Lehre vom muskulaeren Cardiaverschluss. Ztschr klinMed. 1903;50:102.

    Google Scholar 

  11. Liebermann-Meffert D. Surgical anatomy of the esophagogastric junction. Helv Chir Acta. 1981;47(6):667–77.

    CAS  PubMed  Google Scholar 

  12. Korn O, Stein HJ, Richter TH, Liebermann-Meffert D. Gastroesophageal sphincter: a model. Dis Esophagus. 1997;10:105–9.

    CAS  PubMed  Google Scholar 

  13. Stein HJ, Liebermann-Meffert D, DeMeester TR, Siewert JR. Three-dimensional pressure image and muscular structure of the human lower esophageal sphincter. Surgery. 1995;117(6):692–8.

    Article  CAS  PubMed  Google Scholar 

  14. Zaninotto G, DeMeester TR, Schwizer W. The lower esophageal sphincter in health and disease. Am J Surg. 1988;155(1):104–11.

    Article  CAS  PubMed  Google Scholar 

  15. DeMeester TR, Wernly JA, Bryant GH, Little AG, Skinner DB. Clinical and in vitro analysis of determinants of gastroesophageal competence. Am J Surg. 1979;137(1):39–46.

    Article  CAS  PubMed  Google Scholar 

  16. Bonavina L, Evander A, DeMeester TR, Walther B, Cheng SC, Palazzo L, et al. Length of the distal esophageal sphincter and competency of the cardia. Am J Surg. 1986;151(1):25–34.

    Article  CAS  PubMed  Google Scholar 

  17. Braune W. Topographisch-anatomisher Atlas nach Druchschnitten an gefrorenen Cadavern. 1878:113–4 p.

    Google Scholar 

  18. Von Gubaroff A. Ueber den Verschluss des menschlichen Magens an der Cardia. Arch.fAnat u Physiol. 1886:395.

    Google Scholar 

  19. His W. Studien an gehaerteten Leichen ueber Form und Lagerung des menschlichen Magens. Arch Anat u Physiol. 1903;27:345.

    Google Scholar 

  20. Thor KB, Hill LD, Mercer DD, Kozarek RD. Reappraisal of the flap valve mechanism in the gastroesophageal junction. A study of a new valvuloplasty procedure in cadavers. Acta Chir Scand. 1987;153(1):25–8.

    CAS  PubMed  Google Scholar 

  21. Marchand P. The gastroesophageal spincter and the mechanism of regurgitation. Br J Surg. 1955;42:504–13.

    Article  CAS  PubMed  Google Scholar 

  22. Hill LD, Kozarek RA, Kraemer SJM, Aye RW, Mercer CD, Low DE, et al. The gastroesophageal flap valve: in vitro and in vivo observations. Gastrointest Endosc. 1996;44(5):541–7.

    Article  CAS  PubMed  Google Scholar 

  23. Curcic J, Roy S, Schwizer A, Kaufman E, Forras-Kaufman Z, Menne D, et al. Abnormal structure and function of the esophagogastric junction and proximal stomach in gastroesophageal reflux disease. Am J Gastroenterol. 2014;109(5):658–67.

    Article  PubMed  Google Scholar 

  24. Allison PR. Reflux esophagitis, sliding hiatal hernia and the anatomy of repair. Surg Gynecol Obstet. 1951;4(92):419–31.

    Google Scholar 

  25. Mittal RK, Sivri B, Schirmer BD, Heine KJ. Effect of crural myotomy on the incidence and mechanism of gastroesophageal reflux in cats. Gastroenterology. 1993;105(3):740–7.

    Article  CAS  PubMed  Google Scholar 

  26. Soto C, Qi B, Diez-Pardo JA, Tovar JA. Identification of diaphragmatic crural component of gastroesophageal barrier in the rat. Dig Dis Sci. 1997;42(12):2420–5.

    Article  CAS  PubMed  Google Scholar 

  27. Mittal RK, Rochester DF, McCallum RW. Electrical and mechanical activity in the human lower esophageal sphincter during diaphragmatic contraction. J Clin Invest. 1988;81(4):1182–9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  28. Pandolfino JE, Kim H, Ghosh SK, Clarke JO, Zhang Q, Kahrilas PJ. High-resolution manometry of the EGJ: an analysis of crural diaphragm function in GERD. Am J Gastroenterol. 2007;102(5):1056–63.

    Article  PubMed  Google Scholar 

  29. AI-Motabagani MAH. An anatomical study of the phrenoesophageal ligament. J Anat Soc India. 2002;51(1):18–22.

    Google Scholar 

  30. Kwok H, Marriz Y, Al-Ali S, Windsor JA. Phrenoesophageal ligament re-visited. Clin Anat. 1999;12(3):164–70.

    Article  CAS  PubMed  Google Scholar 

  31. Ayazi S, Tamhankar A, DeMeester SR, Zehetner J, Wu C, Lipham JC, et al. The impact of gastric distension on the lower esophageal sphincter and its exposure to acid gastric juice. Ann Surg. 2010;252(1):57–62.

    Article  PubMed  Google Scholar 

  32. Rieder F, Biancani P, Harnett K, Yerian L, Falk GW. Inflammatory mediators in gastroesophageal reflux disease: impact on esophageal motility, fibrosis, and carcinogenesis. Am J Physiol Gastrointest Liver Physiol. 2010;298(5):G571–81.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  33. Lord RVN, Demeester SR, Peters JH, Hagen JA, Elyssnia D, Sheth CT, et al. Hiatal hernia, lower esophageal sphincter incompetence, and effectiveness of Nissen fundoplication in the spectrum of gastroesophageal reflux disease. J Gastrointest Surg. 2009;13(4):602–10.

    Article  PubMed  Google Scholar 

  34. Trudgill NJ, Riley SA. Transient lower esophageal sphincter relaxations are no more frequent in patients with gastroesophageal reflux disease than in asymptomatic volunteers. Am J Gastroenterol. 2001;96(9 Suppl):2569–74.

    Article  CAS  PubMed  Google Scholar 

  35. Ayazi S, Hagen JA, Chan LS, DeMeester SR, Lin MW, Ayazi A, et al. Obesity and gastroesophageal reflux: quantifying the association between body mass index, esophageal acid exposure, and lower esophageal sphincter status in a large series of patients with reflux symptoms. J Gastrointest Surg. 2009;13(8):1440–7.

    Article  PubMed  PubMed Central  Google Scholar 

  36. El-Serag HB, Graham DY, Satia JA, Rabeneck L. Obesity is an independent risk factor for GERD symptoms and erosive esophagitis. Am J Gastroenterol. 2005;100(6):1243–50.

    Article  PubMed  Google Scholar 

  37. Iovino P, Angrisani L, Galloro G, Consalvo D, Tremolaterra F, Pascariello A, et al. Proximal stomach function in obesity with normal or abnormal oesophageal acid exposure. Neurogastroenterol Motil. 2006;18(6):425–32.

    Article  CAS  PubMed  Google Scholar 

  38. Kramer JR, Fischbach LA, Richardson P, Alsarraj A, Fitzgerald S, Shaib Y, et al. Waist-to-hip ratio, but not body mass index, is associated with an increased risk of Barrett’s esophagus in white men. Clin Gastroenterol Hepatol. 2013;11(4):373–81.e1.

    Article  PubMed  Google Scholar 

  39. El-Serag HB, Hashmi A, Garcia J, Richardson P, Alsarraj A, Fitzgerald S, et al. Visceral abdominal obesity measured by CT scan is associated with an increased risk of Barrett’s oesophagus: a case-control study. Gut. 2014;63(2):220–9.

    Article  PubMed  Google Scholar 

  40. Pandolfino JE, El-Serag HB, Zhang Q, Shah N, Ghosh SK, Kahrilas PJ. Obesity: a challenge to esophagogastric junction integrity. Gastroenterology. 2006;130(3):639–49.

    Article  PubMed  Google Scholar 

  41. Howden CW, Henning JM, Huang B, Lukasik N, Freston JW. Hiatal hernia size is the dominant determinant of esophagitis presence and severity in gastroesophageal reflux disease. Am J Gastroenterol. 2001;96(6):1711–7.

    Article  Google Scholar 

  42. Avidan B, Sonnenberg A, Schnell TG, Chejfec G, Metz A, Sontag SJ. Hiatal hernia size, Barrett’s length, and severity of acid reflux are all risk factors for esophageal adenocarcinoma. Am J Gastroenterol. 2002;97(8):1930–6.

    Article  PubMed  Google Scholar 

  43. Cannon WB. Boston society of medical sciences. Bost Soc Med Sci. 1898;2(6):59–66.

    Google Scholar 

  44. Hertz AF. The sensibility of the alimentary canal in health and disease. Am J Med Sci. 1911:132–3.

    Google Scholar 

  45. Clarke AT, Wirz AA, Seenan JP, Manning JJ, Gillen D, McColl KEL. Paradox of gastric cardia: it becomes more acidic following meals while the rest of stomach becomes less acidic. Gut. 2009;58(7):904–9.

    Article  CAS  PubMed  Google Scholar 

  46. Chandrasoma PT, Der R, Ma Y, Dalton P, Taira M. Histology of the gastroesophageal junction: an autopsy study. Am J Surg Pathol. 2000;24(3):402–9.

    Article  CAS  PubMed  Google Scholar 

  47. Lee YY, Mccoll KEL. Disruption of the gastroesophageal junction by central obesity and waist belt: role of raised intra-abdominal pressure. Dis Esophagus. 2015;28:318–25.

    Article  CAS  PubMed  Google Scholar 

  48. McColl KE, Lee TJ. Pathophysiology of gastroesophageal reflux disease. Thorac Surg Clin. 2005;15(3):323–33.

    Article  Google Scholar 

  49. Kahrilas PJ, Lin S, Chen J, Manka M. The effect of hiatus hernia on gastro-oesophageal junction pressure. Gut. 1999;44(4):476–82.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  50. Koch OO, Kaindlstorfer A, Antoniou SA, Asche KU, Granderath FA, Pointner R. Influence of the esophageal hiatus size on the lower esophageal sphincter, on reflux activity and on symptomatology. Dis Esophagus. 2012;25(3):201–8.

    Article  CAS  PubMed  Google Scholar 

  51. Kahrilas PJ, Shi G, Manka M, Joehl RJ. Increased frequency of transient lower esophageal sphincter relaxation induced by gastric distention in reflux patients with hiatal hernia. Gastroenterology. 2000;118(4):688–95.

    Article  CAS  PubMed  Google Scholar 

  52. Kahrilas PJ, Lin S, Manka M, Shi G, Joehl RJ. Esophagogastric junction pressure topography after fundoplication. Surgery. 2000;127(2):200–8.

    Article  CAS  PubMed  Google Scholar 

  53. Louie BE, Kapur S, Blitz M, Farivar AS, Vallières E, Aye RW. Length and pressure of the reconstructed lower esophageal sphincter is determined by both crural closure and Nissen fundoplication. J Gastrointest Surg. 2013;17(2):236–43.

    Article  PubMed  Google Scholar 

  54. Granderath FA, Schweiger UM, Kamolz T, Pointner R. Dysphagia after laparoscopic antireflux surgery: a problem of hiatal closure more than a problem of the wrap. Surg Endosc Other Interv Tech. 2005;19(11):1439–46.

    Article  CAS  Google Scholar 

  55. Farrell TM, Smith CD, Metreveli RE, Richardson WS, Johnson AB, Hunter JG. Fundoplications resist reflux independent of in vivo anatomic relationships. Am J Surg. 1999;177(2):107–10.

    Article  CAS  PubMed  Google Scholar 

  56. Pandolfino JE, Curry J, Shi G, Joehl RJ, Brasseur JG, Kahrilas PJ. Restoration of normal distensive characteristics of the esophagogastric junction after fundoplication. Ann Surg. 2005;242(1):43–8.

    Article  PubMed  PubMed Central  Google Scholar 

  57. Mason RJ, DeMeester TR, Lund RJ, Peters JH, Crookes P, Ritter M, et al. Nissen fundoplication prevents shortening of the sphincter during gastric distention. Arch Surg. 1997;132(7):719–24. discussion 724–6.

    Article  CAS  PubMed  Google Scholar 

  58. Lundell L, Miettinen P, Myrvold HE, Hatlebakk JG, Wallin L, Engström C, et al. Comparison of outcomes twelve years after antireflux surgery or omeprazole maintenance therapy for reflux esophagitis. Clin Gastroenterol Hepatol. 2009;7(12):1292–8.

    Article  PubMed  Google Scholar 

  59. Oelschlager BK, Petersen RP, Brunt LM, Soper NJ, Sheppard BC, Mitsumori L, et al. Laparoscopic paraesophageal hernia repair: defining long-term clinical and anatomic outcomes. J Gastrointest Surg. 2012;16(3):453–9.

    Article  PubMed  Google Scholar 

  60. DeMeester SR. Laparoscopic paraesophageal hernia repair: critical steps and adjunct techniques to minimize recurrence. Surg Laparosc Endosc Percutan Tech. 2013;23(5):429–35.

    Article  PubMed  Google Scholar 

  61. Richter JE. Gastroesophageal reflux disease treatment: side effects and complications of fundoplication. Clin Gastroenterol Hepatol. 2013;11(5):465–71.

    Article  PubMed  Google Scholar 

  62. Horgan S, Pohl D, Bogetti D, Eubanks T, Pellegrini CA. Failed antireflux surgery—what have we learned from reoperations. Arch Surg. 2007;134:809–17.

    Article  Google Scholar 

  63. Hatch KF, Daily MF, Christensen BJ, Glasgow RE. Failed fundoplications. Am J Surg. 2004;188(6):786–91.

    Article  PubMed  Google Scholar 

  64. Mattioli S, Lugaresi ML, Costantini M, Del Genio A, Di Martino N, Fei L, et al. The short esophagus: intraoperative assessment of esophageal length. J Thorac Cardiovasc Surg. 2008;136(4):834–41.

    Article  PubMed  Google Scholar 

  65. Horvath KD, Swanstrom LL, Jobe BA. The short esophagus: pathophysiology, incidence, presentation, and treatment in the era of laparoscopic antireflux surgery. Ann Surg. 2000;232(5):630–40.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  66. Swanstrom LL, Marcus DR, Galloway GQ. Laparoscopic Collis gastroplasty is the treatment of choice for the shortened esophagus. Am J Surg. 1996;171(5):477–81.

    Article  CAS  PubMed  Google Scholar 

  67. Oelschlager BK, Yamamoto K, Woltman T, Pellegrini C. Vagotomy during hiatal hernia repair: a benign esophageal lengthening procedure. J Gastrointest Surg. 2008;12(7):1155–62.

    Article  PubMed  Google Scholar 

  68. Collis JL. An operation for hiatus hernia with short esophagus. Thorax. 1957;12:181–8.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  69. Wilson JL, Bradley DD, Louie BE, Aye RW, Vallières E, Farivar AS. Laparoscopy with left chest collis gastroplasty: a simplified technique for shortened esophagus. Ann Thorac Surg. 2014;98(5):1860–2.

    Article  PubMed  Google Scholar 

  70. Qureshi AP, Aye RW, Buduhan G, Knight A, Orlina J, Farivar AS, et al. The laparoscopic Nissen-Hill hybrid: pilot study of a combined antireflux procedure. Surg Endosc. 2013;27(6):1945–52.

    Article  PubMed  Google Scholar 

  71. Bradley DD, Louie BE, Farivar AS, Wilshire CL, Baik PU, Aye RW. Assessment and reduction of diaphragmatic tension during hiatal hernia repair. Surg Endosc. 2015;29(4):796–804.

    Article  PubMed  Google Scholar 

  72. Huntington TR. Laparoscopic mesh repair of the esophageal hiatus. J Am Coll Surg. 1997;184(4):399–400.

    CAS  PubMed  Google Scholar 

  73. Greene CL, Demeester SR, Zehetner J, Worrell SG, Oh DS, Hagen JA. Diaphragmatic relaxing incisions during laparoscopic paraesophageal hernia repair. Surg Endosc. 2013;27(12):4532–8.

    Article  PubMed  Google Scholar 

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  1. Division of Thoracic Surgery, Swedish Cancer Institute, Swedish Medical Center, 1101 Madison Street, Suite 900, Seattle, WA, 98105, USA

    Andreas M. Schneider M.D. & Brian E. Louie MD, MHA, MPH, FRCSC, FACS

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  1. Andreas M. Schneider M.D.
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  2. Brian E. Louie MD, MHA, MPH, FRCSC, FACS
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Correspondence to Brian E. Louie MD, MHA, MPH, FRCSC, FACS .

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Editors and Affiliations

  1. Thoracic and Foregut Surgery, Swedish Medical Center and Swedish Cancer Institute, Seattle, Washington, USA

    Ralph W. Aye

  2. Department of Surgery, Oregon Health Sciences University, Portland, Oregon, USA

    John Hunter

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Schneider, A.M., Louie, B.E. (2016). Anatomy of the Reflux Barrier in Health, Disease, and Reconstruction. In: Aye, R., Hunter, J. (eds) Fundoplication Surgery. Springer, Cham. https://doi.org/10.1007/978-3-319-25094-6_1

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