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J Thorac Cardiovasc Surg 1998;116:267-275
© 1998 Mosby, Inc.

General Thoracic Surgery

Clinical and surgical relevance of the progressive phases of intrathoracic migration of the gastroesophageal junction in gastroesophageal reflux disease

From the Center for the Study and Therapy of Diseases of the Esophagus of the University of Bologna,^a Department of Surgery, Intensive Care, and Organ Transplantation, and Clinical Department of Radiological Sciences and Pathology,^b University of Bologna, Bologna, Italy.

Received for publication May 21, 1997. Revisions requested August 6, 1997; revisions received March 2, 1998. Accepted for publication March 2, 1998. Reprint requests: Sandro Mattioli, MD, Dipartimento di Discipline Chirugiche, Rianimatorie e dei Trapianti, Sezione Chirurgia Generale, Università di Bologna, Via Massarenti, 9, 40138 Bologna, Italy.

Objective: The pathophysiologic influence of progressive intrathoracic migration of the gastroesophageal junction axial to the esophagus on gastroesophageal reflux disease was investigated.
Methods: A radiologic-manometric study was performed on hiatal insufficiency, concentric hiatus hernia, and short esophagus, the three radiologic steps of intrathoracic gastroesophageal junction migration, and on healthy volunteers. The distances between inferior and superior margins of the lower esophageal sphincter and the diaphragm were measured. Endoscopic, manometric, and pH-metric evaluations were performed after barium swallow in 38 patients with severe gastroesophageal reflux disease and sliding hiatus hernia with intraabdominally reducible gastroesophageal junction, in 35 patients with hiatal insufficiency, in 40 with concentric hiatus hernia, and in 19 with short esophagus.
Results: The distance from the lower esophageal sphincter inferior margin to the diaphragm was different in healthy volunteers (–2.6 ± 0.9 cm [standard deviation]) versus that in patients with hiatal insufficiency (–1.0 ± 0.7 cm; p = 0.02), concentric hiatus hernia (–0.8 ± 1.0 cm; p = 0.02), and short esophagus (4.0 ± 2.5 cm; p = 0.0002), and in patients with short esophagus versus hiatal insufficiency (p = 0.0002) and concentric hiatus hernia (p = 0.0002). Lower esophageal sphincter tone was reduced between healthy volunteers (19 ± 9.1 mm Hg [standard deviation]) and patients with sliding hiatus hernia (12 ± 7.2 mm Hg; p = 0.02), hiatal insufficiency (10 ± 5.9 mm Hg; p = 0.0001), concentric hiatus hernia (7 ± 3.1 mm Hg; p = 0.00002), and short esophagus (7  ± 3.7 mm Hg; p = 0.00003) and between concentric hiatus hernia versus sliding hiatus hernia (p = 0.007). Acid gastroesophageal reflux total time percent was increased between healthy volunteers (2.4% ± 1.8% [standard deviation]) and patients with sliding hiatus hernia (12.8% ± 7.8%; p = 0.02), hiatal insufficiency (17.2% ± 15.8%; p = 0.0001), concentric hiatus hernia (24.0% ± 19.6%; p = 0.00002), and short esophagus (26.1% ± 19.6%; p = 0.00002) and between sliding hiatus hernia versus concentric hiatus hernia (p = 0.002) and short esophagus (p = 0.01).
Conclusions: Permanent gastroesophageal junction orad migration axial to the esophagus has greater pathophysiologic relevance on gastroesophageal reflux disease than sliding hiatus hernia with an intraabdominally reducible gastroesophgeal junction. Hiatal insufficiency, concentric hiatus hernia, and short esophagus are markers of progressively increasing irreversible cardial incontinence and therefore indications for surgical therapy.

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