A proposed classification for uniform endoscopic description of surgical fundoplication

Assessment of laparoscopic fundoplication with endoscopy: room for improvement

INTRODUCTION

Gastroesophageal reflux disease affects a significant portion of the Australian and world population. Minimally invasive laparoscopic fundoplication is a highly effective treatment in appropriately selected patients, with a 90% satisfaction rate. However, up to 5% will undergo revisional surgery. Endoscopy is an important investigation in the evaluation of persistent or new symptoms after fundoplication. Our study sought to evaluate the inter-rater reliability and variability in assessing fundoplication with endoscopy.

METHODS

Upper gastrointestinal (UGI) surgeons and gastroenterologists were invited to join the cohort study through their professional membership with two societies based in Australia. Participants completed a two part 25-item multiple choice questionnaire, involving the analysis of ten static endoscopic images post-fundoplication.

RESULTS

A total of 101 participants were included in the study (64 UGI surgeons and 37 gastroenterologists). Over 95% of participants were consultant level, working in non-rural tertiary hospitals. Total accuracy for all 10 cases combined was 76% for UGI surgeons and 69.9% for gastroenterologists. In three of the 10 cases, UGI surgeons performed significantly better than gastroenterologists (p < 0.05). When assessing performance across each of the 4 questions for each case, UGI surgeons were more accurate than gastroenterologists in describing the integrity of the wrap (p = 0.014). Inter-rater reliability was low across both groups for most domains (kappa < 1).

CONCLUSION

Our study confirms low inter-rater reliability between endoscopists and large variations in reporting. UGI surgeons performed better than gastroenterologists in certain cases, usually when describing the integrity of the fundoplication. Our study provides further support for the use of a standardized reporting system in post-fundoplication patients.

ENDOSCOPIC EVALUATION OF POST-FUNDOPLICATION ANATOMY AND CORRELATION WITH SYMPTOMATOLOGY

Background:

Upper digestive endoscopy is important for the evaluation of patients submitted to fundoplication, especially to elucidate postoperative symptoms. However, endoscopic assessment of fundoplication anatomy and its complications is poorly standardized among endoscopists, which leads to inadequate agreement.

Aim:

To assess the frequency of postoperative abnormalities of fundoplication anatomy using a modified endoscopic classification and to correlate endoscopic findings with clinical symptoms.

Method:

This is a prospective observational study, conducted at a single center. Patients were submitted to a questionnaire for data collection. Endoscopic assessment of fundoplication was performed according to the classification in study, which considered four anatomical parameters including the gastroesophageal junction position in frontal view (above or at the level of the pressure zone); valve position at retroflex view (intra-abdominal or migrated); valve conformation (total, partial, disrupted or twisted) and paraesophageal hernia (present or absent).

Results:

One hundred patients submitted to fundoplication were evaluated, 51% male (mean age: 55.6 years). Forty-three percent reported postoperative symptoms. Endoscopic abnormalities of fundoplication anatomy were reported in 46% of patients. Gastroesophageal junction above the pressure zone (slipped fundoplication), and migrated fundoplication, were significantly correlated with the occurrence of postoperative symptoms. There was no correlation between symptoms and conformation of the fundoplication (total, partial or twisted).

Conclusion:

This modified endoscopic classification proposal of fundoplication anatomy is reproducible and seems to correlate with symptomatology. The most frequent abnormalities observed were slipped and migrated fundoplication, and both correlated with the presence of symptoms.

Endoscopic Evaluation of Post-Fundoplication Anatomy

PURPOSE OF REVIEW

We aim to review the endoscopic evaluation 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). Endoscopic evaluation of post-fundoplication anatomy 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 repairs 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 evaluation systems in order for such tools to become widely accepted.

Association of Body Mass Index (BMI) with Patterns of Fundoplication Failure: Insights Gained

BACKGROUND

Obesity has been implicated as an important risk factor for fundoplication failure. However, the mechanism of fundoplication in obese patients is not fully understood. Our objective is to evaluate the patterns of failure in relation to the body mass index (BMI) undergoing re-operative intervention after failed fundoplication.

METHODS

After Institutional Review Board approval, the patients who underwent re-operative intervention for failed fundoplication between November 2008 and December 2013 were identified. Patients were classified into three groups: non-obese, obese, and morbidly obese (<30, 30-35, >35 BMI, respectively). Pre-operative assessment and operative procedure performed were compared between the groups.

RESULTS

One hundred twenty-four patients satisfied study criteria. Non-obese patients (53.2 %) had significantly more dysphagia as an indication for re-operative procedure (obese 31.6 %, p < 0.05; morbidly 16.7 %, p < 0.05). Obese and morbidly obese patients had significantly higher incidence of recurrent hiatal hernia than non-obese patients (88.7 vs. 65.6 %, p < 0.05). Morbidly obese patients had significantly higher incidence of disrupted fundoplication than non-obese patients (41.7 vs. 19.4 %, p < 0.05).

CONCLUSION

Similar anatomical failure patterns of state of fundoplication and recurrent hiatal hernia were noted between obese patients and morbidly obese patients and were distinct from non-obese patients.