What should be included in an endoscopic report for a patient with a history of GERD who has undergone a Nissen fundoplication?

Endoscopic Report Documentation for Post-Nissen Fundoplication Patients

Essential Pre-Procedure Documentation

Document the original indication for fundoplication surgery, including the severity of pre-operative GERD (LA classification grade), duration of symptoms, and failure of medical management. 1, 2 This establishes baseline context for interpreting current findings.

• Record current symptoms systematically: heartburn, regurgitation, dysphagia, gas-bloat syndrome, inability to belch or vomit, and aspiration symptoms 2, 3
• Note time elapsed since fundoplication surgery, as complications and wrap integrity change over time 4, 5
• Document current medication regimen, particularly proton pump inhibitor use, which may indicate treatment failure 4
• Specify the type of fundoplication performed (total Nissen vs. partial wrap), as this affects expected findings and complication patterns 6

Critical Intra-Procedure Technical Elements

Use high-definition white light endoscopy as the minimum standard, and document the specific endoscopic equipment and imaging modalities employed. 1

• Systematically examine and document the fundoplication wrap position relative to the gastroesophageal junction 4, 5
• Assess wrap integrity: intact 360-degree wrap, slipped wrap, disrupted wrap, or wrap migration into the chest 6, 5
• Measure wrap tightness by assessing ease of scope passage through the wrap—resistance suggests excessive tightness causing dysphagia 6, 3
• Evaluate for hiatal hernia recurrence or paraesophageal hernia formation, which occurs in 20-30% of failures 6, 5

Specific Anatomical Findings to Document

Precisely describe the position and appearance of the fundoplication wrap, as wrap integrity is the main determinant of long-term outcome. 5

• Document wrap location: properly positioned at the gastroesophageal junction, slipped distally into stomach, or herniated into chest 6, 5
• Describe wrap configuration: symmetric 360-degree wrap, asymmetric wrap, or partial disruption 5
• Note the presence of the "neo-cardia" created by the wrap and its appearance 4
• Assess for wrap-related complications: erosion into esophageal mucosa, ischemic changes, or excessive scarring 6

Esophageal Mucosa Assessment

Systematically evaluate the esophageal mucosa for erosive esophagitis using the Los Angeles classification, as reflux control failure occurs in approximately 20% of patients long-term. 4, 5

• Grade any erosive esophagitis present using LA classification (Grade A-D) 1, 2
• Document Barrett's esophagus if present, noting extent (short-segment vs. long-segment), as this develops in 5-7% of post-fundoplication patients 4, 5
• Assess for stricture formation at or above the wrap level 6, 3
• Note mucosal changes suggesting persistent acid exposure despite the wrap 4, 5

Gastric Findings Below the Wrap

• Examine the gastric fundus and body for retained food, suggesting delayed gastric emptying or wrap obstruction 6
• Document gastric mucosa appearance and any erosions or ulcerations 4
• Assess for gastric distension or dilation, which may indicate gas-bloat syndrome 2, 3

Mandatory Biopsy Protocol

Obtain targeted biopsies from the esophagogastric junction and any abnormal mucosa, specifying exact anatomical location and number of samples. 1, 4

• Take biopsies from the esophagogastric junction to assess for carditis regression or persistence 4
• Obtain biopsies from any Barrett's mucosa for dysplasia surveillance 4, 5
• Sample any erosive esophagitis areas to confirm inflammation and rule out other pathology 1
• Document the exact location (distance from incisors), number, and indication for each biopsy set 1

Therapeutic Interventions During Endoscopy

If post-fundoplication dysphagia is present with a tight wrap, consider balloon dilation to 30-40 mm diameter. 6

• Document balloon dilation parameters: balloon size, inflation pressure, duration, and number of dilations performed 6
• Describe any endoscopic incision techniques if performed for refractory strictures 6
• Note steroid injection if administered, though this carries increased risk of esophageal candidiasis 6
• Record immediate response to intervention and any complications 1

Adverse Events Documentation

Immediately document any complication including bleeding, perforation, or cardiopulmonary events, with description of interventions and patient response. 1

• Describe the nature and severity of any bleeding encountered 1
• Document signs of perforation or wrap disruption if suspected 6
• Record interventions performed and their effectiveness 1

Post-Procedure Synthesis and Diagnosis

Provide a clear endoscopic diagnosis comparing current findings to previous examinations, specifically addressing wrap integrity and reflux control. 1, 5

• State whether the fundoplication wrap is intact, partially disrupted, or completely failed 5
• Assess reflux control: excellent (no esophagitis, intact wrap), partial (mild esophagitis despite intact wrap), or failed (severe esophagitis, disrupted wrap) 4, 5
• Compare findings to any previous endoscopic examinations to determine progression or stability 1, 4
• Correlate endoscopic findings with patient symptoms (Visick classification I-IV) 4

Explicit Follow-Up Recommendations

Recommend upper GI endoscopy, manometry, pH studies, and barium swallow for patients with persistent dysphagia to assess wrap integrity before considering revision surgery. 6

• Specify timing of next surveillance endoscopy based on findings: annually for Barrett's esophagus, every 2-3 years for stable post-fundoplication without complications 6, 1
• Recommend 24-hour pH-impedance monitoring if symptoms suggest reflux recurrence despite intact-appearing wrap 6, 2
• Suggest barium swallow to assess wrap position and esophageal emptying if dysphagia is prominent 6, 2
• Recommend surgical consultation if wrap disruption, herniation, or severe obstruction is identified 6
• Adjust or intensify PPI therapy if erosive esophagitis is present despite intact wrap 6, 4