Comparison of anterior, posterior and total fundoplication using a viscera model

Abstract

<h4>Objective</h4>To determine the contribution of mechanical factors to the function of different types of fundoplication.<h4>Design and setting</h4>An experimental bench-top study using abattoir-sourced pig esophagus and stomach placed on a tray. Preliminary esophageal myotomy ensured free reflux of 'intragastric fluid'.<h4>Interventions</h4>Anterior, posterior, and total fundoplications were performed on each of ten sets of viscera.<h4>Main outcome measures</h4>Lower esophageal sphincter pressure was measured using a conventional esophageal manometry catheter. Intragastric pressure was measured with a single channel intragastric manometry catheter, whilst the stomach was inflated with coloured water. The maximum intragastric pressure or the pressure measured when the fundoplication yielded to gastric distension was recorded.<h4>Results</h4>All three types of fundoplication restored adequate competence to the gastroesophageal junction, although high-volume gastric infusions resulted in fundoplication yield in 4/10 anterior and 4/10 posterior fundoplications. Gastric distension resulted in fundal dilatation and consequent compression of the adjacent esophagus. Fundoplication generated a median rise of 11-13.5 mmHg in lower esophageal sphincter pressure, comparable to pressures reported in the postoperative clinical setting. Significantly greater intragastric volumes and pressures were tolerated following total fundoplication.<h4>Conclusions</h4>This study suggests that mechanical factors could be major contributors to the ability of a fundoplication to restore gastroesophageal competence. Anterior, posterior and total fundoplications are all effective procedures.