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Laparoscopic Nissen fundoplication is currently considered the surgical treatment of choice for gastroesophageal reflux disease (GERD) and its long-term effectiveness is above 90%. Adequate patient selection and the experience of the surgeon are among the predictive factors of good clinical response. However, there can be new, persistent, and recurrent symptoms after the antireflux procedure in up to 30% of the cases. There are numerous causes, but in general, they are due to one or more anatomic abnormalities and esophageal and gastric function alterations. When there are persistent symptoms after the surgical procedure, the surgery should be described as "failed". In the case of a patient that initially manifests symptom control, but the symptoms then reappear, the term "dysfunction" could be used. When symptoms worsen, or when symptoms or clinical situations appear that did not exist before the surgery, this should be considered a "complication". Postoperative dysphagia and dyspeptic symptoms are very frequent and require an integrated approach to determine the best possible treatment. This review details the pathophysiologic aspects, diagnostic approach, and treatment of the symptoms and complications after fundoplication for the management of GERD.

BACKGROUND Endoscopic ultrasound (EUS) and endoscopic ultrasound elastography (EUS-E) simulation lessens the learning curve; however, models lack realism, diminishing competitiveness. AIM To standardize the mechanical properties of polyvinyl alcohol (PVA) hydrogel for simulating organs and digestive lesions. METHODS PVA hydrogel (Sigma Aldrich, degree of hydrolysis 99%) for simulating EUS/EUS-E lesions was investigated in Unidad de Investigación y Desarrollo Tecnológico at Hospital General de México “Dr. Eduardo Liceaga”, Mexico City. We evaluated physical, contrast, elasticity and deformation coefficient characteristics in lesions, applying Kappa’s concordance and satisfaction questionnaire (Likert 4-points). RESULTS PVA hydrogel showed stable mechanical properties. Density depended on molecular weight (MW) and concentration (C). PVA bblocks with the greatest density showed lowest tensile strength ( r = -0.8, P = 0.01). Lesions were EUS-graphically visible. Homogeneous and heterogeneous examples were created from PVA blocks or PVA phantoms, exceeding (MW 2 = 146000-186000, C 9 = 15% and C 10 = 20%) with a density under (MW 1 = 85000-124000, C 1 = 7% and C 2 = 9%). We calculated elasticity and deformation parameters of solid (blue) areas, contrasting with the norm (Kappa = 0.8; high degree of satisfaction). CONCLUSION PVA hydrogels were appropriate for simulating organs and digestive lesions using EUS/EUS-E, facilitating practice and reducing risk. Repetition amplified skills, while reducing the learning curve.

Background and study aims The light blue crest observed in narrow band imaging endoscopy has high diagnostic accuracy for diagnosis of gastric intestinal metaplasia (GIM). The objective of this prospective study was to evaluate the diagnostic accuracy of magnifying i-scan optical enhancement (OE) imaging for diagnosing the LBC sign in patients with different levels of risk for gastric cancer in a Mexican clinical practice. Patients and methods Patients with a history of peptic ulcer and symptoms of dyspepsia or gastroesophageal reflux disease were enrolled. Diagnosis of GIM was made at the predetermined anatomical location and white light endoscopy and i-scan OE Mode 1 were captured at the two predetermined biopsy sites (antrum and pyloric regions). Results A total of 328 patients were enrolled in this study. Overall GIM prevalence was 33.8 %. The GIM distribution was 95.4 % in the antrum and 40.5 % in the corpus. According to the Operative Link on Gastritis/Intestinal-Metaplasia Assessment staging system, only two patients (1.9 %) were classified with high-risk stage disease. Sensitivity, specificity, positive​ and negative predictive values, positive and negative likelihood ratios, and accuracy of both methods (95 % C. I.) were 0.50 (0.41–0.60), 0.55 (0.48–0.62), 0.36 (0.31–0.42), 0.68 (0.63–0.73), 1.12 (0.9–1.4), 0.9 (0.7–1.1), and 0.53 (0.43–0.60) for WLE, and 0.96 (0.90–0.99), 0.91 (0.86–0.94), 0.84 (0.78–0.89), 0.98 (0.94–0.99), 10.4 (6.8–16), 0.05 (0.02–0.12), and 0.93 (0.89–0.95), respectively. The kappa concordance was 0.67 and the reliability coefficient was 0.7407 for interobserver variability. Conclusions Our study demonstrated the high performance of magnifying i-scan OE imaging for endoscopic diagnosis of GIM in Mexican patients.