Variations in Endoscopic Description of Failed Fundoplications

Arpad Juhasz, MD PhD, Abhishek Sundaram, MBBS MPH, Masato Hoshino, MD, Tommy H Lee, MD, Sumeet K Mittal, MD. Department of Surgery, Creighton University Medical Center

Objective: The objective of this study was to compare endoscopic findings reported by community physicians (gastroenterologists and surgeons) with our (a tertiary referral center) findings in patients who underwent re-operative intervention after a previous anti-reflux surgery. Parallel with the meteoric rise in the number of laparoscopic anti-reflux procedures, there has been an increase in the number of patients who require a re-operative procedure. Pre-operative endoscopic assessment of the failed fundoplication is instrumental in diagnosis and surgical management. Endoscopy is a routine and essential part of the work up of a failed fundoplication, however there are no clear guidelines to report endoscopic findings.

Methods: Retrospective review of a prospectively maintained database was performed to identify patients who underwent re-operation after a failed anti-reflux surgery between 12/01/2003 and 06/30/2010. Endoscopic findings as reported by the outside physician and by the operating surgeon were reviewed and compared.

Results: Two hundred twenty-nine patients underwent re-operation in the study period. Fifteen patients did not have endoscopy performed by an outside physician prior to assessment at our institution. 208 patients met the eligibility criteria and were included in this study. Of these 75 were males and 133 were females with a mean age of 54.6 years. The endoscopic reports of the operating physician included 97 cases of hiatal hernia (Type I – 64, Type II and III – 33), 52 slipped fundoplications, 61 disrupted fundoplications, 30 intrathoracic fundoplications, 6 two-compartment stomachs, 27 Barrett’s esophagus. Outside physicians identified 87 % of the hiatal hernias and 61% of the paraesophageal hernias reported by us. Only 32% of the outside reports mentioned a previous fundoplication. Furthermore only 17% and 30% of the slipped and disrupted fundoplications respectively, were described by outside physicians. Outside physicians identified 63% of the patients with Barrett’s esophagus.

Conclusion: There is poor agreement between community endoscopists and those at tertiary care centers in the endoscopic descripton of previous fundoplications. Community physicians often fail to identify fundoplications and rarely use accepted terminology. A standardized classification system of endoscopic findings after an anti-reflux procedure is needed.