Curr Gastroenterol Rep (2017) 19:51
DOI 10.1007/s11894-017-0592-7
ESOPHAGUS (J CLARKE AND N AHUJA, SECTION EDITORS)
Endoscopic Evaluation of Post-Fundoplication Anatomy
Walaa F. Abdelmoaty 1 & Lee L. Swanstrom 2,3
# Springer Science+Business Media, LLC 2017
Abstract
Purpose of Review We aim to review the endoscopic evalua-
tion of post-fundoplication anatomy and its role in assessment
of fundoplication outcomes and in pre-operative planning for
reoperation in failed procedures.
Recent Findings There is no universally accepted system for
evaluating post-fundoplication anatomy endoscopically.
However, multiple reports described the usefulness of post-
operative endoscopy as a quality control measure and in the
evaluation of complex cases such as repeat procedures and
paraesophageal hernias (PEH).
Summary Endoscopic evaluation of post-fundoplication anato-
my has an important role in assessing the outcomes of operative
repair and pre-operative planning for failed fundoplications.
Attempts have been made to characterize the appearance of
the newly formed gastroesophageal valve after successful re-
pairs and to standardize endoscopic reporting and classification
of anatomic descriptions of failed fundoplications. However,
there is no consensus. More studies are needed to evaluate the
applicability and reproducibility of proposed endoscopic evalu-
ation systems in order for such tools to become widely accepted.
Keywords Endoscopy . Post-fundoplication .
Gastroesophageal valve . Gastroesophageal junction
anatomy . Fundoplication . Redo fundoplication
This article is part of the Topical Collection on Esophagus
* Lee L. Swanstrom
lswanstrom@gmail.com
1
Providence Portland Medical Center, Portland, OR, USA
2
The Oregon Clinic, 4805 NE Glisan St, Suite 6N60,
Portland, OR 97213, USA
3
Institute for Image Guided Surgery, Strasbourg, France
Introduction
The importance of endoscopic evaluation of post-fundoplication
anatomy is related to the necessity of restoring normal gastro-
esophageal junction (GEJ) geometry and by extension an effec-
tive anti-reflux mechanism. Normal geometry is achieved by
returning the gastroesophageal junction to the abdomen, closing
the hiatal opening, and creating a one-way valve mechanism
[1••]. The normal gastroesophageal flap valve (GEFV), the
intraluminal extension of the angle of His [2], is a 180° flap
valve that opposes the lesser curvature of the stomach when
the gastric pressure rises preventing stomach contents from
refluxing into the esophagus and it allows, only, for the one-
way passage of contents from the esophagus into the stomach
[3, 4]. Hill et al. described a grading system based on endoscopic
views in retroflexion of valve geometry that is a widely used
indicator of reflux status [5–7]. When this geometry is distorted,
for example due to a hiatal hernia, the gastric cardia becomes
patulous due to the permanent attenuation of collar sling fibers,
and the GEFV is lost [8, 9]. Loss of the GEFV contributes to the
loss of the anti-reflux mechanism or, at least, to the loss of
resistance to reflux episodes with rises in gastric pressure [10].
It has been shown that the loss of the GEFV predisposes the
patient to an increased frequency of transient lower esophageal
sphincter relaxation [11].
Fundoplication surgery approximates the greater curvature
aspect of the cardia (collar sling fibers) toward the lesser cur-
vature aspect (clasp fibers) in order to restore the distal high-
pressure zone and to reconstruct the angle of His and a highly
competent valve mechanism [8]. By wrapping the proximal
stomach around the distal 3 cm of the esophagus, an acute
angle at the level of GEJ is created, and an endoscopically
evident valve is formed. Thus, when gastric pressure rises,
the greater curvature aspect of the cardia is pushed against
the lesser curvature aspect, mimicking the native valve
51 Page 2 of 8
mechanism in resisting gastric reflux [1••]. It is interesting to
note that fundoplications resist reflux independent of in vivo
anatomic relationships, as the length of the newly constructed
valve does not decrease in relation to gastric distention [12].
The fundoplication type determines the appearance character-
istics of the newly formed valve; as such, it is important to
understand how the valve is formed as well as the unique
anatomic characteristics of each valve type.
Despite the high rate of satisfaction after fundoplication
surgeries, post-operative complaints are not unusual [13–18].
With the adoption of laparoscopic techniques in the early
1990s, the frequency of fundoplication surgery increased ex-
ponentially [19, 20]. The increasing number of fundoplication
surgeries has been accompanied by an increasing number of
dissatisfied patients [21•, 22••]. Patients with recurrent, persis-
tent, or new-onset symptoms need a thorough evaluation in
order to determine their etiology. Endoscopic evaluation is the
first test to be used in the assessment of post-fundoplication
symptoms [1••], as it can help to differentiate between symp-
toms attributable to a technical problem with surgery and
those attributable to a new esophageal lesion or disease pro-
cess [23, 24]. Endoscopic evaluation may be used to further
subcategorize treatment failures and to tailor the next most
appropriate intervention [22••].
Despite the generally acknowledged importance of endoscop-
ic evaluation, there is no consensus on how to document these
diagnostic findings [1••, 21•, 22••, 23]. Terminology varies wide-
ly among reports of post-fundoplication anatomy [21•]. A vali-
dated, universally accepted lexicon and reporting system would
be useful for objectively evaluating the results of fundoplication
surgeries. Likewise, a consensus on what do and do not consti-
tute normal findings following different types of fundoplication
would be important to further classify failures and select appro-
priate subsequent management strategies. Proposals exist regard-
ing unique characteristics of post-fundoplication valve anatomy
[1••] and classification systems for treatment failures [21•], but
they need to be validated for feasibility and reproducibility.
Subjective assessments should be replaced by objective criteria
that make endoscopic evaluation a more dependable outcome
measure of fundoplication surgery.
What is Normal Endoscopic Anatomy After
a Successful Fundoplication?
The ideal fundoplication lies intraabdominally below a closed
hiatus and wraps symmetrically around the GEJ [22••]. Jobe
et al. described a system of 10 criteria to assess fundoplication
anatomy, with particular attention to the newly constructed gas-
troesophageal valve (GEV) [1••]. To define successful proce-
dures clinically, they excluded any patient with post-operative
symptoms of heartburn, regurgitation, dysphagia, chest pain, or
gas bloat, or any patient still using anti-secretory medications.
Curr Gastroenterol Rep (2017) 19:51
The authors theorized that these criteria could reflect, objective-
ly, the function of the anti-reflux mechanism.
The devised characterization system incorporates findings
relevant to complete wraps, such as the Nissen or Collis-
Nissen, and partial wraps such as the Toupet, Dor or the Hill
repair. Although all procedures work toward the same function-
al outcome, they have different valve appearances when viewed
with a retroflexed endoscope. Complete fundoplications
(Nissen and Collis-Nissen) and Hill repairs create a nipple type
valve, whereas partial fundoplications (Toupet and Dor) result
in a flap valve type. Partial fundoplications may exhibit some
opening associated with respiration whereas complete
fundoplications do not. The 10 specific valve criteria applied
to the five different types of fundoplications are described in
Table 1 and illustrated in Figs. 1 and 2.
However, the system is marked by several limitations.
There were no follow-up studies to test the system’s reproduc-
ibility and ease of use. Proven correlations between endoscop-
ic valve descriptions and patient satisfaction, residual symp-
toms, quality of life surveys, and additional objective testing
(e.g., manometry, pH testing, and intraluminal impedance) are
also lacking at present and would be important to underscore
the clinical relevance of this system. Some of the authors’
criteria are subjectively framed, such as groove evaluation,
which is described as “shallow” or “deep,” and lesser curva-
ture width, which is described as “narrow” or “wide”; replace-
ment of these simple adjectives with clearly defined grading
scales would help to minimize discrepancies among different
endoscopists.
Finally, this characterization system was based on descrip-
tions of static images from among patients who had one of the
previously mentioned fundoplication surgeries. It was not in-
dicated how long those patients were out of surgery when
these images were taken or if there were any available com-
parisons with other post-surgery images from different dates.
Evaluation of these criteria over time would be critical to
determine their dependability. Symptom control generally de-
creases over time in accordance with changes in anatomic
configuration. Stefanidis et al. showed that symptom control
decreases from 90% at 3 years to 67% at 7 years [25]. Other
studies have shown that persistent relief of heartburn and re-
gurgitation was achieved in 90 and 80% of patients at 10-
[26–28] and 20-year [29–31] follow-up, respectively. Formal
study of valve criteria immediately after surgery and at dis-
crete follow-up time points is recommended to understand the
temporal robustness of these criteria for wrap functionality.
Endoscopic Evaluation of Post-fundoplication
Symptoms
Usually, assessment of post-fundoplication anatomy is war-
ranted when patients report symptoms. Endoscopic evaluation
Curr Gastroenterol Rep (2017) 19:51 Page 3 of 8 51

Table 1 Valve characteristics and rating system adopted from Jobe et al. [1••]

Valve criteria Nissen Collis-Nissen Toupet Dor Hill

Lip thickness Thin Thick Thick Wide Thin
width of the most distal
aspect of the valve
Body length 3–4 cm 3 cm 3 cm 3 cm 4–5 cm
distance from fundus
apex to the valve lip
Anterior groove Shallow Absent Shallow Shallow Deep
impression depth made
by the repair
Posterior groove Deep Shallow Shallow Absent Deep
impression depth made
by the repair
Lesser curvature width Narrow Wide Wide Wide Wide
area directly behind the
endoscope
Adherence to endoscope Tight Tight Moderate Moderate Tight
tightness of valve lip
around the endoscope
Respiration Adherent all Periods of opening Brief periods of Occasional opening No opening
adherence of the valve phases around scope in opening during during respiration during respiration
to the endoscope was inspiration respiration
during respiration
Type Nipple Nipple Flap Flap Nipple
Intraabdominal location Yes Yes Yes Yes Yes
Proper repair position Yes Yes Yes Yes Yes
Unique characteristics Body has Spiral appearance; Omega-shaped lip S-shaped lip Lesser curve has comet
stacked coils staple line evident tail appearance;
appearance on body smooth body

of post-fundoplication symptoms is seen as an effective test to
assess failed fundoplication anatomy [35] and to correlate
post-fundoplication symptoms with anatomic findings [21•].
With the widespread adoption of laparoscopic fundoplication
techniques as the gold standard surgical treatment modality
for gastroesophageal reflux disease (GERD), the number of
patients who are persistently or recurrently symptomatic after
fundoplication surgeries has increased significantly [19, 20].
Reflux recurs at a rate of 3–30% among patients post-
fundoplication, with 3–6% requiring repeat surgery due to
persistent or recurrent symptoms [32].
The goal of endoscopic assessment of post-fundoplication
symptoms is to look for objective signs of uncontrolled reflux,
evaluate for unrelated or de novo lesions, and to assess the
fundoplication itself for technical problems or failure [23].
Post-fundoplication symptoms can be classified according to
their relationship to preoperative symptoms as persistent, re-
current, or new post-operatively [23]. The presence of ero-
sions or ulceration indicates that persistent symptoms are
due to a failed fundoplication, whereas evidence of alternative
disease processes such as peptic ulcer, Candida esophagitis, or
eosinophilic esophagitis may indicate that the initial symp-
toms were attributable to a cause other than GERD [23, 24].
For new symptoms such as dysphagia, endoscopy can detect
related post-operative technical problems, such as a disrupted,
slipped, or twisted fundoplication, or new lesions, such as a
stricture or neoplasm [23, 24].
As the endoscope is advanced, the endoscopist can assess for
a tight fundoplication by the appearance of coils (puckering) at
the distal esophagus and the sense of excessive force required to
traverse the distal esophagus. A slipped fundoplication can be
signaled by the finding of a gastric mucosal pouch proximal to
the wrap, which indicates either that the stomach has slid upward
or that the wrap was incorrectly positioned to begin with around
the proximal stomach rather than the distal esophagus [23].
Positioning the endoscope in retroflexion and facing the less-
er curvature facilitates inspection of the newly constructed valve.
A disrupted fundoplication can be expected if the anterior
groove is absent or if the posterior groove is shallow. Surgical
material may be seen in the gastric body if and where the wrap
has separated. In the case of a partially disrupted Nissen
fundoplication, the nipple valve stacked coils will appear loose
around the endoscope shaft. If the configuration of these stacked
coils is oblique rather than parallel to the diaphragm, it may
indicate a twisted or ill-constructed fundoplication. A herniated
fundoplication can appear as an intact fundoplication with the
entire segment pushed upward into the chest and the crural folds
positioned below the fundoplication. Endoscopy in retroflexion
also can help detect the development of new PEH after the
fundoplication by revealing a gastric pouch above the level of
51 Page 4 of 8
Fig. 1 Diagrams of valve appearance of different types of
fundoplications. a Nissen fundoplication. b Nissen-Collis
fundoplication. c Toupet fundoplication. d Dor fundoplication, e Hill
the diaphragm, either passing through the wrap or next to it [23].
As always, correlation with patients’ symptoms is necessary to
determine the clinical relevance of these findings.
Endoscopic Evaluation Reporting Problems
Non-uniform reporting remains a clear limitation to the endo-
scopic evaluation of post-fundoplication anatomy. At present,
there is no agreement on defined anatomic irregularities, clas-
sification schemes, or severity scoring. The need for a consen-
sus is compelling because systematized reports among different
providers would facilitate a more thorough detection of post-
operative problems, a better mechanistic understanding of treat-
ment failures, and wiser planning for future management.
Endoscopic evaluation is usually performed by gastroenter-
ologists, primary care physicians, and surgeons. Discrepancies
in the description of endoscopic findings among these provider
Curr Gastroenterol Rep (2017) 19:51
repair diagram. This figure is a property of the Foundation for Surgical
Innovation and Education (FSEI); FSEI grants permission to use it
classes are marked. Juhasz et al. reported significant discor-
dance in reported endoscopic findings post-fundoplication be-
tween community physicians and experienced esophageal sur-
geons for patients who underwent re-operative intervention af-
ter a failed fundoplication. The authors attributed this discrep-
ancy to a lack of universally accepted endoscopic terminology
and to a lack of systematic training. The study found that gen-
eral endoscopists’ reports captured only 32% of previous
fundoplications, 68% of hiatal hernias, 61% of paraesophageal
hernias, 17% of slipped fundoplications, 30% of disrupted
fundoplications, and 70% of Barrett’s esophagus cases [21•].
Uniform Endoscopic Description of Surgical
Fundoplication
Because of the lack of uniformity and wide discordance
among endoscopists in the description of post-fundoplication
Curr Gastroenterol Rep (2017) 19:51
Fig. 2 a Nissen fundoplication. b Nissen-Collis fundoplication. c Toupet
fundoplication. d Dor fundoplication. This figure is a property of the
Foundation for Surgical Innovation and Education (FSEI); FSEI grants
permission to use it
Page 5 of 8 51
anatomy, the need to find a consensus is of utmost importance.
For this reason, Mittal et al. proposed a classification system
for standardized endoscopic reporting of post-fundoplication
anatomy [22••]. The classification included four factors: E
(distance of GEJ to crus), S (amount of gastric tissue between
the GEJ and fundoplication), F (fundoplication configuration),
and P (paraesophageal hernia) (Table 2). The system was pro-
posed mainly as a means of subcategorizing patients who had
failed surgery toward developing a better algorithm for surgi-
cal retreatment.
As an example, a normal fundoplication in this classifica-
tion would be described as E0S0F0P0. The GEJ is positioned
intraabdominally and below the crura (E0); there is no slippage
of the fundoplication, and it is securely wrapped around the
distal esophagus (S0); the fundoplication looks symmetric and
competent (F0); and there is no paraesophageal hernia detect-
ed (P0). The system can also be used to describe different
types of fundoplications by using different combinations of
criteria. However, it is important to note that the authors
grouped fundoplications with any slippage component togeth-
er, regardless of their E and F criteria status, explaining that
such slippage overrides other anatomical derangements.
The study by Mittal et al. demonstrated that altered post-
fundoplication anatomy correlated with presenting symptoms.
Dysphagia and chest pain were more likely to occur with a
twisted fundoplication due to distal obstruction, whereas re-
current heartburn and regurgitation were more often associat-
ed with disrupted fundoplications. Slipped fundoplications
could be associated with any symptom and tended to represent
a complete treatment failure. Despite these correlations, this
study did not include all symptomatic post-fundoplication pa-
tients in its analysis, instead selecting explicitly for those who
underwent repeat surgeries. Better validity for this classifica-
tion scheme would be achieved via analysis of all symptom-
atic and non-symptomatic patients.
While this classification scheme can help surgeons to plan
systematically for repeat intervention, the study authors did not
recommend using it as a sole measure for the assessment the
post-fundoplication symptoms or as a replacement for current
standards. Rather, it should be considered an additional tool to
streamline reporting and enable accurate comparisons across
different centers. It should also be noted that the classification
is not completely objective; a wrap score of E1 versus E2 or S1
versus S2 relies on the endoscopist’s judgment and experience.
Endoscopic Evaluation and Other Tests
High-Resolution Manometry
Endoscopic evaluation can also be correlated with other tests
in order to detect or confirm symptom etiologies and mecha-
nisms of treatment failure. Hoshino et al., for example,
51 Page 6 of 8
Table 2 Classification of the
endoscopic findings of “E” component
fundoplication adopted from E0
Mittal et al. [22••] E1
E2
“S” component
S0
S1
S2
“F” component
F0
F1a
F1b
F2a
F2b
“P” component
P0
P1
demonstrated significant correlation between high-resolution
manometry (HRM) patterns and endoscopic findings for
symptomatic patients after a previous fundoplication [33]. In
this study, two patients with endoscopically intact,
intraabdominal fundoplications showed a dual high-pressure
zone (HPZ) on HRM, a finding that the authors attributed to
the possibility on an intermittently telescoping fundoplication
into the chest. A distinct dual HPZ configuration was other-
wise detected in intra-thoracic and slipped fundoplications
only, the distal HPZ representing the diaphragmatic crus and
the proximal HPZ representing the fundoplication around the
native LES. The authors hypothesized that the utility of HRM
might be highest in assessing post-fundoplication symptoms
in the setting of normal endoscopic findings.
It should be noted that this study did not consider asymptom-
atic patients with previous fundoplication, a group that might
have served as useful controls. Normal HRM measurements for
asymptomatic post-fundoplication patients should be codified
before HRM can be considered a robust and objective assess-
ment system for post-fundoplication symptoms. In a subsequent
study assessing HRM findings in symptomatic, endoscopically
intact Nissen fundoplications, the same group of investigators
demonstrated that nearly 25% of symptomatic patients had an
intact endoscopic anatomical configuration and that those
reporting dysphagia had longer HPZ complexes and higher in-
tegrated relaxation pressures (IRP) [34]. However, this study
also did not consider asymptomatic post-operative controls,
and the study population (43 patients) was relatively small.
Esophagram
In a study of the diagnostic usefulness of endoscopic evalua-
tion of Nissen fundoplication anatomical derangements,
Curr Gastroenterol Rep (2017) 19:51
Distance of GEJ to the level of crura
GEJ is located intra-abdominally, at or under the level of crura
GEJ is located less than 2 cm above the level of crura
GEJ is located more than 2 cm above the level of crura
Amount of gastric tissue above the fundoplication and below the GEJ
Fundoplication is around the distal esophagus
Less than 2 cm gastric tissue above the fundoplication
More than 2 cm gastric tissue above the fundoplication
Description of the fundoplication
Intact fundoplication (competent, symmetrical)
Partially disrupted fundoplication
Completely disrupted fundoplication
Twisted fundoplication
Two-compartment stomach
Present of paraesophageal hernia (verified by endoscopy or esophagogram)
No PEH
Recurrent PEH
Jailwala et al. concluded that endoscopy performed better than
esophagram by detecting disturbed anatomy twice as often in
most but not all circumstances. The one exception was an
overly tight wrap, which esophagram was superior to endos-
copy at detecting. [24].
Endoscopic Ultrasound
In an observational animal study, Gopal et al. demonstrated that
endoscopic ultrasound (EUS) evaluation of anatomy at the level
of the hiatus is feasible and provides useful information regard-
ing Nissen fundoplication integrity and its relationship to the
diaphragm. The study defined a set of endosonographic criteria
that characterize a normal Nissen fundoplication and the ana-
tomic derangements associated with repair failure in a swine
model. The study concluded that EUS can precisely determine
the anatomic causes and mechanisms of treatment failure after
Nissen fundoplication [39].
In a follow-up clinical trial to the previous study, these
defined sets of endosonographic criteria were tested for valid-
ity in humans [40]. The study showed that the application of
these criteria to all subjects was easy and that EUS had a
greater ability to detect causes and mechanism of treatment
failure than other conventional tests combined. However, the
study suggested that EUS is best used among those symptom-
atic patients in whom conventional testing did not yield a
coherent etiologic explanation, likely due to the reliance of
EUS evaluation on operator expertise. In addition, the study
hypothesized that EUS combined with upper endoscopy could
serve as the only test required to determine the necessity of a
repeat operation. However, the performance characteristics of
this approach could not be assessed, as the study population
Curr Gastroenterol Rep (2017) 19:51
was small and did not correlate its findings with outcomes
after repeat surgery.
Conclusion
Endoscopic evaluation of post-fundoplication anatomy is an
important tool in the assessment of wrap integrity and in the
explanation of post-operative symptoms. Physicians and sur-
geons tend to utilize endoscopy to evaluate post-
fundoplication anatomy only if the patient has symptoms after
the procedure. Persistent symptoms may indicate an ineffec-
tive surgery or incorrect diagnosis, whereas new symptoms
are most likely related to an abnormality of the wrap itself
[24]. The role of upper endoscopy in asymptomatic patients
is less clear and limited to routine follow-up visits.
Despite the fact that the number of re-operative interven-
tions after laparoscopic fundoplication surgeries has dramati-
cally increased over the years, there is no change in the pattern
or presenting symptoms of failed procedures or in the indica-
tions for repeat intervention. Patterns of endoscopic derange-
ment also have not changed over time [23]. A lack of universal
agreement on terminology used to describe the anatomical
findings and on a systemic approach to reporting has made it
difficult to formalize this diagnostic maneuver into a set of
defined metrics. Lingering subjectivity in the process of endo-
scopic evaluation has also contributed to the current lack of
consensus. Furthermore, the accuracy of tests like endoscopy
for the assessment of potentially failed fundoplications has
been reported as low [42].
Attempts have been made and are ongoing to reach a wide-
ly accepted agreement on the vocabulary used to describe
anatomical findings after fundoplication surgeries and to unify
definitions across reports. Proposed criteria, with their defini-
tions and grades, have introduced a lexicon to describe the
anatomical configuration after a successful fundoplication as
well as a classification system for failed procedures. Even so,
no clear guidelines exist for reporting endoscopic findings yet
[21•].
Successful outcomes after redo surgeries decrease to 66
and to 50% after third and fourth operations, respectively
[41]. The outcomes of repeated fundoplications are less satis-
factory than primary surgeries [36–38]. The ability to stratify
patients according to discrete patterns of fundoplication failure
patterns will help detecting those who are at risk for poor
outcomes and allow for proper counseling and improved ther-
apeutic decision-making [23]. With the aid of additional ob-
jective testing modalities, a scoring system could be useful in
assessing fundoplication surgery outcomes and in predicting
high-risk patients in the context of considering a repeat pro-
cedure. A consensus meeting among leaders in the field may
facilitate establishing each of these necessary reference
standards.
Page 7 of 8 51
Compliance with Ethical Standards
Conflict of Interest Walaa Abdelmoaty declares no conflict of interest.
Lee Swanstrom reports non-financial support from Apollo, Boston
Scientific, and Olympus and grants from Olympus, outside the submitted
work.
Human and Animal Rights and Informed Consent This article does
not contain any studies with human or animal subjects performed by any
of the authors.
References
Papers of particular interest, published recently, have been
highlighted as:
• Of importance
•• Of major importance
1.•• Jobe BA, Kahrilas PJ, Vernon AH, Sandone C, Gopal DV,
Swanstrom LL, et al. Endoscopic appraisal of the gastroesophageal
valve after antireflux surgery. Am J Gastroenterol. 2004;99(2):233–
43. This study is considered the first attempt to characterize the
endoscopic findings of normal successful fundoplications and
proposed an endoscopic lexicon to report these criteria.
2. Liebermann-Meffert D, Allgower M, Schmid P, et al. Muscular
equivalent of the lower esophageal sphincter. Gastroenterology.
1979;76:31–8.
3. Adler RH, Firme NC, Lanigan JM. A valve mechanism to prevent
gastroesophageal reflux and esophagitis. Surgery. 1958;44:63–75.
4. Hill LD, Kozarek RA. The gastroesophageal flap valve. J Clin
Gastroenterol. 1999;28:1947.
5. Hill LD, Kozarek RA, Kraemer SJ, et al. The gastroesophageal flap
valve: in vitro and in vivo observations. Gastrointest Endosc.
1996;44:541–7.
6. Contractor QQ, Akhtar SS, Contractor TQ. Endoscopic esophagitis
and gastroesophageal flap valve. J Clin Gastroenterol. 1999;28:
233–7.
7. Oberg S, Peters JH, DeMeester TR, et al. Endoscopic grading of the
gastroesophageal valve in patients with symptoms of gastroesoph-
ageal reflux disease (GERD). Surg Endosc. 1999;13:1184–8.
8. Korn O, Csendes A, Burdiles P, et al. Anatomic dilation of the
cardia and competence of the lower esophageal sphincter: a clinical
and experimental study. J Gastrointest Surg. 2000;4:398–406.
9. Klein WA, Parkman HP, Dempsey DT, et al. Sphincterlike
thoracoabdominal high pressure zone after esophagogastrectomy.
Gastroenterology. 1993;105:1362–9.
10. Fein M, Ritter MP, DeMeester TR, et al. Role of lower esophageal
sphincter and hhiatal hernia in the pathogenesis of gastroesophageal
reflux disease. J Gastrointest Surg. 1999;3:405–10.
11. Kahrilas PJ, Shi G, Manka M, et al. Increased frequency of transient
lower esophageal sphincter relaxation induced by gastric distention
in reflux patients with hiatal hernia. Gastroenterology. 2000;118:
688–95.
12. Farrell TM, Smith CD, Metreveli RE, et al. Fundoplications resist
reflux independent of in vivo anatomic relationships. Am J Surg.
1999;177:107–10.
13. Bammer T, Hinder RA, Klaus A, et al. Five- to eight-year outcome
of the first laparascopic Nissen fundoplications. J Gastrointest Surg.
2001;5:42–8.
14. Anvari M, Allen C. Five-year comprehensive outcomes evaluation
in 181 patients after laparascopic Nissen fundoplication. J Am Coll
Surg. 2003;196:51–9.
51 Page 8 of 8
15. Catarci M, Gentileschi P, Papi C, et al. Evidence-based appraisal of
antireflux fundoplication. Ann Surg. 2004;239:325–37.
16. Dassinger MS, Torquati A, Houston HL, et al. Laparoscopic
fundoplication: 5-year follow-up. Am Surg. 2004;70:691–4.
17. Lafullarde T, Watson DI, Jamieson GG, et al. Laparoscopic Nissen
fundoplication: five year results and beyond. Arch Surg. 2001;136:
180–4.
18. Peters JH, DeMeester TR, Crookes P, et al. The treatment of gas-
troesophageal reflux disease with laparoscopic Nissen
fundoplication: prospective evaluation of 100 patients with “typi-
cal” symptoms. Ann Surg. 1998;228:40–50.
19. Finks JF, Wei Y, Birkmeyer JD. The rise and fall of antireflux
surgery in the United States. Surg Endosc. 2006;20:1698–701.
20. Jay AP, Watson ID. Changing work patterns for benign upper gas-
trointestinal and biliary disease: 1994-2007. ANZ J Surg. 2010;80:
519–25.
21.• Juhasz A, Sundaram A, Hoshino M, Lee TH, Mittal SK.
Endoscopic assessment of failed fundoplication: a case for stan-
dardization. Surg Endosc. 2011;25(12):3761–6. This study de-
fined the problems and lack of uniformity in the description
of endoscopic post-fundoplication findings.
22.•• Mittal SK, Juhasz A, Ramanan B, Hoshino M, Lee TH, Filipi CJ. A
proposed classification for uniform endoscopic description of surgical
fundoplication. Surg Endosc. 2014;28:1103–9. This study proposed
the first classification system in an attempt to standardize the
reporting system for endoscopic post-fundoplication findings.
23. Stark ME, Devault KR. Complications following fundoplication.
Tech Gastrointest Endosc. 2006;8:40–53.
24. Jailwala J, Massey B, Staff D, Shaker R, Hogan W. Post-
fundoplication symptoms: the role for endoscopic assessment of
fundoplication integrity. Gastrointest Endosc. 2001;54(3):351–6.
25. Stefanidis D, Hope WW, Kohn GP, Reardon PR, Richardson WS,
Fanelli RD, et al. Guidelines for surgical treatment of gastroesoph-
ageal reflux disease. Surg Endosc. 2010;24:2647–69.
26. Broeders JA, Rijnhart-de Jong HG, Draaisma WA, Bredenoord AJ,
Smout AJ, Gooszen HG. Ten-year outcome of laparoscopic and
conventional nissen fundoplication: randomized clinical trial. Ann
Surg. 2009;250:698–706.
27. Ross SB, Gal S, Teta AF, Luberice K, Rosemurgy AS. Late results
after laparoscopic fundoplication denote durable symptomatic relief
of gastroesophageal reflux disease. Am J Surg. 2013;206:47–51.
28. Dallemagne B, Weerts J, Markiewicz S, Dewandre JM, Wahlen C,
Monami B, et al. Clinical results of laparoscopic fundoplication at
ten years after surgery. Surg Endosc. 2006;20:159–65.
Curr Gastroenterol Rep (2017) 19:51
29. Dallemagne B, Perretta S. Twenty years of laparoscopic
fundoplication for GERD. World J Surg. 2011;35:1428–35.
30. Mardani J, Lundell L, Engström C. Total or posterior partial
fundoplication in the treatment of GERD: results of a randomized
trial after 2 decades of follow-up. Ann Surg. 2011;253:875–8.
31. Engström C, Cai W, Irvine T, Devitt PG, Thompson SK, Game PA,
et al. Twenty years of experience with laparoscopic antireflux sur-
gery. Br J Surg. 2012;99:1415–21.
32. Celasin H, Genc V, Celik SU, Turkcapar AG. Laparoscopic revision
surgery for gastroesophageal reflux disease. Medicine. 2017;96:1–
4.
33. Hoshino M, Srinivasan A, Mittal SK. High-resolution manometry
patterns of lower esophageal sphincter complex in symptomatic
post-fundoplication patients. J Gastrointest Surg. 2012;16:705–14.
34. Yamamoto SR, Akimoto S, Hoshino M, Mittal SK. High-resolution
manometry findings in symptomatic post-Nissen fundoplication
patients with normal endoscopic configuration. Dis Esophagus.
2016;29:967–70.
35. Iqbal A, Awad Z, Simkins J, Shah R, Haider M, Salinas V, et al.
Repair of 104 failed antireflux operations. Ann Surg. 2006;244:42–
51.
36. Furnee EJ, Draaisma WA, Broeders IA, Gooszen HG. Surgical
reintervention after failed antireflux surgery: a systematic review
of the literature. J Gastrointest Surg. 2009;13:1539–49.
37. Khajanchee YS, O’Roukre R, Cassera MA, Gatta P, Hansen PD,
Swanstrom LL. Laparoscopic reintervention for failed antireflux
surgery. Arch Surg. 2007;142(8):785–92.
38. Hunter JG, Smith CD, Braunum GD, Waring JP, Trus TL, Cornwell
M, et al. Laparoscopic fundoplication failures: patterns of failure
and response to fundoplication revision. Ann Surg. 1999;230(4):
595–606.
39. Gopal DV, Chang EY, Kim CY, Sandone C, Pfau PR, Frick TJ, et al.
EUS characteristics of Nissen fundoplication: normal appearance
and mechanisms of failure. Gastrointest Endosc. 2006;63:35–44.
40. Chang EY, Minjarez RC, Kim CY, Seltman AK, Gopal DV, Diggs
B, et al. Endoscopic ultrasound for the evaluation of Nissen
fundoplication integrity: a blinded comparison with conventional
testing. Surg Endosc. 2007;21:1719–25.
41. Skinner DB. Surgical management after failed antireflux opera-
tions. World J Surg. 1992;16:359–63.
42. Horgan S, Pohl D, Bogetti D, Eubanks T, Pellegrini C. Failed
antireflux surgery: what have we learned from reoperations? Arch
Surg. 1999;134:809–15.