Improving accuracy in identifying the gastroesophageal junction during laparoscopic antireflux surgery

Background: Proper construction of an effective fundoplication to control reflux depends on accurate identification of the gastroesophageal junction (GEJ). In laparoscopic surgery, the accuracy of this GEJ determination is unknown. Methods: In 40 consecutive laparoscopic antireflux procedures, the GEJ location was determined independently by endoscopy and laparoscopy, and the differences were measured. After this was completed, endoscopic examination of the fundoplication was performed. Results: The "laparoscopic" GEJ was identified within 1 cm of the "endoscopic" GEJ in 36 of 40 (90%) patients. In four patients, this difference was greater and the GEJ always higher than determined by laparoscopy. These patients had greater acid exposure and esophageal injury. On two occasions, the fundoplication was reconstructed on the basis of endoscopic findings. Conclusions: With laparoscopy, the surgeon can accurately determine the GEJ location in most patients. In approximately 10%, the GEJ is actually higher than the surgeon believes, and the fundoplication may be created lower than intended. Intraoperative endoscopy helps to identify the GEJ location and evaluate the wrap once completed.