Endoscopy and Antireflux Surgery: A Technical Review of Pre- and Postoperative Evaluation and Recognizing Patterns of Failure

Endoscopic evaluation after antireflux surgery is a challenge, due to the complexity of anatomy, variations in anatomical repairs, and the various patterns of failure. Studies have demonstrated that endoscopy reports of postoperative examinations are often inaccurate and inconsistent. The key to consistent high quality endoscopic examinations of the integrity of an antireflux surgery is a sound foundation in the native anatomical gastroesophageal junction and an understanding of the anatomy of the various postoperative configurations. This review will clarify the critical details necessary to perform a detailed endoscopic evaluation of the patient with suspected gastroesophageal reflux, and highlight key features to distinguish the intact repair from the dysfunctional one. It first explores the anatomical components of the native gastroesophageal junction and the unique geometric architecture that manifests in the physiologic reflux barrier. Then details the essential structures to evaluate and techniques to perform in an endoscopic examination prior to an antireflux surgery. It then systematically examines the altered anatomy and postoperative changes in endoscopic appearance after Nissen, Toupet, and Dor fundoplication, Collis gastroplasty, magnetic sphincter augmentation, and transoral incisionless fundoplication. Finally, to aid in the endoscopic diagnosis of specific dysfunction, it discusses the various patterns of failure after antireflux surgery, their characteristic endoscopic appearances, and the most useful adjunct testing modalities to augment the endoscopic examination when diagnosis is unclear.