Is endoscopic gastric fundoplication indicated for a patient with a small ring in the mid esophagus, diffuse erythema and a 2 cm type 2 hiatus hernia, mild duodenitis with erosions, and symptoms of gastroesophageal reflux disease (GERD)?

Endoscopic Fundoplication is NOT Indicated for This Patient

This patient is NOT a candidate for endoscopic gastric fundoplication due to the presence of a 2 cm hiatal hernia, which exceeds the size threshold for endoscopic procedures. If anti-reflux surgery is ultimately needed after proper workup and failed medical management, laparoscopic fundoplication with hiatal hernia repair would be the appropriate surgical approach 1, 2, 3.

Critical Contraindications Present

The endoscopic findings reveal several factors that make endoscopic fundoplication inappropriate:

• The 2 cm hiatal hernia is a contraindication for endoscopic fundoplication, which should only be performed in patients with small or no hiatal hernia (typically <2 cm) 1, 2, 3
• The presence of erosive changes (diffuse erythema, Hill type 2, duodenitis with erosions) suggests active inflammation that requires medical optimization first 1
• The mid-esophageal rings with white patches raise concern for possible eosinophilic esophagitis or other esophageal pathology that must be evaluated with biopsy results before considering any anti-reflux procedure 2

Required Diagnostic Workup Before ANY Anti-Reflux Procedure

Before considering any invasive anti-reflux intervention, the following must be completed:

• Objective confirmation of pathologic GERD through ambulatory 24-hour pH-impedance monitoring (preferably off PPI therapy initially, then on PPI if symptoms persist despite optimization) 1, 2, 3
• High-resolution manometry to exclude achalasia and assess esophageal peristaltic function, as impaired motility would influence the type of fundoplication if surgery becomes necessary 1, 2, 3
• Review of esophageal and gastric biopsies to exclude eosinophilic esophagitis (given the rings and white patches), Barrett's esophagus, and to confirm the degree of inflammation 2, 3
• Barium swallow may be useful to better characterize the hiatal hernia anatomy and assess for esophageal shortening 1

Appropriate Management Algorithm

Step 1: Medical Optimization (Current Priority)

• Initiate or optimize PPI therapy with twice-daily dosing if once-daily is insufficient 1, 3
• Address lifestyle modifications including weight loss if obese, dietary triggers, and positional therapy 1
• Treat the erosive esophagitis, gastritis, and duodenitis with adequate acid suppression for 8-12 weeks 1, 3
• Await biopsy results to exclude eosinophilic esophagitis or other pathology 2, 3

Step 2: Objective Testing (If Symptoms Persist After 4-8 Weeks)

• Perform ambulatory pH-impedance monitoring to confirm pathologic GERD and characterize reflux patterns 1, 2, 3
• Complete high-resolution manometry to assess esophageal motility 1, 2, 3
• Consider gastric emptying study if symptoms suggest delayed emptying 1

Step 3: Surgical Consideration (Only If Medical Therapy Fails AND Testing Confirms GERD)

• Laparoscopic fundoplication with hiatal hernia repair is the appropriate surgical option for this patient given the 2 cm hiatal hernia 1, 3, 4
• The choice between complete Nissen (360°) or partial fundoplication (Toupet 270° or Dor) should be based on esophageal motility findings—partial fundoplication is preferred if esophageal hypomotility or impaired peristaltic reserve is present to reduce postoperative dysphagia risk 1, 4
• Magnetic sphincter augmentation combined with crural repair is another surgical option for confirmed GERD with hiatal hernia 1

Common Pitfalls to Avoid

• Do not proceed with endoscopic fundoplication in the presence of hiatal hernia >2 cm—this is associated with high failure rates and the hernia itself requires surgical repair 1, 2, 3
• Do not perform any anti-reflux procedure without objective GERD confirmation—patients with functional heartburn (normal pH studies) have poor surgical outcomes 3
• Do not skip manometry—undiagnosed achalasia or severe esophageal dysmotility can lead to devastating postoperative dysphagia 1, 2, 3
• Do not rush to surgery—ensure adequate trial of optimized medical therapy (twice-daily PPI for at least 4-8 weeks) before considering invasive procedures 1, 3

If Surgery Becomes Necessary

Should this patient fail medical management and meet all criteria for anti-reflux surgery:

• Laparoscopic fundoplication with hiatal hernia repair remains the gold standard with 80% success rates at 20-year follow-up 5, 4
• The hiatal hernia must be reduced and the crural defect repaired, potentially with mesh reinforcement if tension-free closure cannot be achieved 6
• Postoperative outcomes are optimized when surgery is performed in PPI-responsive patients who develop side effects or complications from long-term PPI use, or in carefully selected PPI-refractory patients with objective GERD confirmation 5, 4