Post-fundoplication contrast studies: is there room for improvement?

Objective: Since the mid-1990s, laparoscopic fundoplication for gastro-oesophageal reflux disease has become the surgical procedure of choice. Several surgical groups perform routine post-operative contrast studies to exclude any (asymptomatic) anatomical abnormality and to expedite discharge from hospital. The purpose of this study was to determine the accuracy and interobserver reliability for surgeons and radiologists in contrast study interpretation. Methods: 11 surgeons and 13 radiologists (all blinded to outcome) retrospectively reviewed the contrast studies of 20 patients who had undergone a laparoscopic fundoplication. Each observer reported on fundal wrap position, leak or extravasation of contrast and contrast hold-up at the gastro-oesophageal junction (on a scale of 0-4). A kappa coefficient was used to evaluate interobserver reliability. Results: Surgeons were more accurate than radiologists in identifying normal studies (specificity=91.6% vs 78.9%), whereas both groups had similar accuracy in identifying abnormal studies (sensitivity=82.3% vs 85.2%). There was higher agreement amongst surgeons than amongst radiologists when determining wrap position (kappa=0.65 vs 0.54). Both groups had low agreement when classifying a wrap migration as partial or total (kappa=0.33 vs 0.06). Radiologists were more likely to interpret the position of the wrap as abnormal (relative risk=1.25) while surgeons reported a greater degree of hold-up of contrast at the gastro-oesophageal junction (mean score=1.17 vs 0.86). Conclusion: Radiologists would benefit from more information about the technical details of laparoscopic anti-reflux surgery. Standardised protocols for performing post-fundoplication contrast studies are needed.