Crural closure, not fundoplication, results in a significant decrease in lower esophageal sphincter distensibility.

Area of Science:

• Gastroenterology
• Surgical Innovation
• Medical Device Technology

Background:

• The esophagogastric junction (EGJ) is a critical anti-reflux barrier, involving the lower esophageal sphincter (LES) and crural diaphragm.
• The relative importance of crural closure versus fundoplication in restoring EGJ competency after hiatal hernia repair remains unclear.

Purpose of the Study:

• To investigate the impact of crural closure and fundoplication on LES minimum diameter (Dmin) and distensibility index (DI) during hiatal hernia repair.
• To assess the correlation between subjective surgeon assessment of crural tightness and objective FLIP measurements.

Main Methods:

• Prospective data collection using a standardized operative endoluminal functional lumen imaging probe (FLIP) protocol during 97 hiatal hernia repairs.
• FLIP measurements (Dmin, DI) were recorded before dissection, after reduction, after cruroplasty, and after fundoplication.
• Surgeons rated crural closure tightness on a 1-5 scale, correlated with FLIP data.

Main Results:

• Crural closure significantly decreased LES Dmin (13.84 to 10.27 mm) and DI (6.81 to 2.85 mm²/mmHg) (p < 0.0001).
• Fundoplication caused a small but significant increase in Dmin and DI (p < 0.0001).
• Subjective crural tightness correlated with DI (r = -0.466, p < 0.001), with tightness ≥4.5 linked to DI < 2.0 mm²/mmHg.

Conclusions:

• Cruroplasty significantly reduces LES distensibility, suggesting it plays a primary role in restoring EGJ competency post-hiatal hernia repair.
• Objective FLIP evaluation confirms that surgeon's subjective assessment of crural tightness is a reliable indicator of anti-reflux barrier function.