There remains an important role for anti-reflux surgery despite the widespread use and effectiveness of proton pump inhibitors. Very large hiatal hernias can be very symptomatic and are not uncommonly found in patients with dysplastic Barrett’s esophagus (BE). Correction of the hiatal hernia can improve symptoms, and many of these patients may be able to stop taking PPIs. Patients with regurgitation particularly benefit from a fundoplication. There is only limited long-term data of the benefit of repairing a hiatal hernia in dysplastic BE in terms of preventing recurrence or progression of the dysplasia [3]. However, it is known that after BE ablation, recurrence of dysplasia is not a rare event [4]. So theoretically, at least, HH repair may be of benefit in patients with dysplastic BE. In fact, Velanovich reported in his series of patients significant improvements in recurrence of BE and persistence of BE in patients who had a Nissen fundoplication before, at the same time as, or after ablation [5].

There are several different hiatal hernia repairs that have been described, and each may have benefit in specific cases. In the present day, these are almost always done laparoscopically [6]. The standard repair is a Nissen fundoplication, which is a 360° “wrap” of the fundus around the distal esophagus in association with reducing the stomach down from the mediastinum into the abdomen. A Dor fundoplication is an anterior wrap generally between 90 and 180°. This is a less robust procedure regarding control of reflux; but, it is advantageous in situations where a tighter wrap is not desired (i.e., patients with motility disorders). A Toupet fundoplication creates a 270° posterior wrap. The Hill repair recreates the angle of His and does not wrap the fundus around at all and is largely of historical significance. A Collis fundoplasty, or esophageal lengthening procedure, may be required in patients with foreshortened esophagus, where the stomach cannot be easily pulled down into the abdominal cavity.

There are subtle differences in endoscopic appearance of fundoplication between the different surgeries [7]. However, the Nissen is the most common done fundoplication. It has an appearance of “stacked coins” with a deep posterior groove and a shallower anterior groove (Fig. 8.8). A Dor or Toupet is similar, but the wrap does not go completely around. It may not be obvious that a patient had a Collis fundoplasty, as the surgical changes are typically covered by the wrap. As mentioned above, the proper position of a fundoplication is around the distal esophagus. Thus, endoscopically, the GEJ should be located beneath the pinch of the diaphragm/top of the fundoplication (often very close and indistinguishable from one another). If the GEJ can be seen above this level, it likely represents some degree of malposition of the fundoplication which can be associated with dysphagia.