BACKGROUND: This study was performed to confirm the presence and significance of a gastroesophageal flap valve. METHODS: The pressure gradient needed to induce reflux across the gastroesophageal junction and the level of a high-pressure zone were determined in 13 cadavers. On inspection in the cadavers, a mucosal flap valve at the entrance of the esophagus into the stomach was seen through a gastrostomy. This valve was deficient or absent in cadavers with a hiatal hernia. The valve was inspected in controls and in patients with reflux with a retroflexed endoscope. RESULTS: In cadavers with no hiatal hernia, a gradient across the gastroesophageal junction was present in nearly all cadavers. The gradient could be increased by surgically accentuating the valve without a concomitant rise in pressure in the high-pressure zone. Reduction of the hiatal hernia in the cadaver and anchoring of the gastroesophageal junction to the normal attachment to the preaortic fascia restored the valve and the gradient as seen through a gastrostomy. Control subjects had a prominent fold of tissue that extended 3 to 4 cm along the lesser curve of the stomach and tightly grasped the shaft of the endoscope. This was diminished or absent in reflux patients. Inspection of the valve in control subjects and subjects with reflux allowed for a grading system with Grades I through IV. This grading system was applied to a cohort of patients with and without reflux. The appearance of the flap valve was a better predictor of the presence or absence of reflux than was lower esophageal sphincter pressure. Endoscopic viewing of the valve during surgery can confirm that a competent valve has been reconstructed. CONCLUSIONS: Grading of the gastroesophageal valve is simple, reproducible, and offers useful information in the evaluation of patients with suspected reflux undergoing endoscopy.
BACKGROUND: This study was performed to confirm the presence and significance of a gastroesophageal flap valve. METHODS: The pressure gradient needed to induce reflux across the gastroesophageal junction and the level of a high-pressure zone were determined in 13 cadavers. On inspection in the cadavers, a mucosal flap valve at the entrance of the esophagus into the stomach was seen through a gastrostomy. This valve was deficient or absent in cadavers with a hiatal hernia. The valve was inspected in controls and in patients with reflux with a retroflexed endoscope. RESULTS: In cadavers with no hiatal hernia, a gradient across the gastroesophageal junction was present in nearly all cadavers. The gradient could be increased by surgically accentuating the valve without a concomitant rise in pressure in the high-pressure zone. Reduction of the hiatal hernia in the cadaver and anchoring of the gastroesophageal junction to the normal attachment to the preaortic fascia restored the valve and the gradient as seen through a gastrostomy. Control subjects had a prominent fold of tissue that extended 3 to 4 cm along the lesser curve of the stomach and tightly grasped the shaft of the endoscope. This was diminished or absent in reflux patients. Inspection of the valve in control subjects and subjects with reflux allowed for a grading system with Grades I through IV. This grading system was applied to a cohort of patients with and without reflux. The appearance of the flap valve was a better predictor of the presence or absence of reflux than was lower esophageal sphincter pressure. Endoscopic viewing of the valve during surgery can confirm that a competent valve has been reconstructed. CONCLUSIONS: Grading of the gastroesophageal valve is simple, reproducible, and offers useful information in the evaluation of patients with suspected reflux undergoing endoscopy.
Authors: In Kyung Yoo; Weon Jin Ko; Hak Su Kim; Hee Kyung Kim; Jung Hyun Kim; Won Hee Kim; Sung Pyo Hong; Abdullah Özgür Yeniova; Joo Young Cho Journal: Surg Endosc Date: 2019-05-28 Impact factor: 4.584
Authors: Toshitaka Hoppo; Arul Immanuel; Matthew Schuchert; Zdenek Dubrava; Andrew Smith; Peter Nottle; David I Watson; Blair A Jobe Journal: J Gastrointest Surg Date: 2010-09-28 Impact factor: 3.452
Authors: Joshua A Boys; Beina Azadgoli; Mathew Martinez; Daniel S Oh; Jeffrey A Hagen; Steven R DeMeester Journal: J Gastrointest Surg Date: 2020-06-30 Impact factor: 3.452
Authors: Aafke H C van Roon; George C Mayne; Bas P L Wijnhoven; David I Watson; Mary P Leong; Gabriëlle E Neijman; Michael Z Michael; Andrew R McKay; David Astill; Damian J Hussey Journal: J Gastrointest Surg Date: 2008-05-02 Impact factor: 3.452
Authors: Jennifer R Kramer; Lori A Fischbach; Peter Richardson; Abeer Alsarraj; Stephanie Fitzgerald; Yasser Shaib; Neena S Abraham; Maria Velez; Rhonda Cole; Bhupinderjit Anand; Gordana Verstovsek; Massimo Rugge; Paola Parente; David Y Graham; Hashem B El-Serag Journal: Clin Gastroenterol Hepatol Date: 2012-12-04 Impact factor: 11.382