Reconstruction of the Antireflux Barrier: The Evolving Conceptual Framework of Fundoplication Symmetry From the AFS Antireflux Barrier Collaborative
Ninh T. Nguyen, Christy M. Dunst, Peter J. Kahrilas, Francis Paul Buckley, Barham Abu Dayyeh, Prakash Gyawali, Kenneth Chang, Ravinder K. Mittal, Dan Lister, Reginald Bell, Lee Swanstrom, Brant K. Oelschlager, John LiphamBackground:
Efforts to reduce adverse side-effects of the classic Nissen 360° fundoplication have largely focused on reducing wrap circumference to a partial fundoplication described as anterior or posterior (with the point of reference being the anterior of the body), while the role of fundoplication symmetry has not been examined. This opinion piece from the American Foregut Society (AFS) Anti-Reflux Barrier (ARB) Collaborative evaluates the evolving concept of fundoplication symmetry in the context of ARB function and its surgical restoration.
Methods:
The AFS Anti-Reflux Barrier Collaborative met monthly (2024-2026) to evaluate commonly performed fundoplications with respect to anterior–posterior symmetry, using the angle of His as a reference point. Expert consensus and relevant historical literature were reviewed.
Results:
Fundoplications are traditionally classified as anterior, posterior, complete, or partial based on wrap location and circumference. However, when assessed by the degree of anterior versus posterior fundic contact with the esophagus, substantial variability exists. These technical distinctions are rarely detailed in outcome reports. Examples include symmetric fundoplications such as Nissen Anterior-Posterior, Belsey Mark IV, combined transoral incisionless, and Lind 300°, and asymmetric fundoplications such as the Nissen-Rosetti, Toupet, and partial anterior. Transition to minimally invasive surgery has shifted the construction from complete to partial wraps and reduced anterior–posterior symmetry. The ARB Collaborative suggests that restoring symmetric stabilization of the gastroesophageal flap valve with a 90° bare area of esophagus on the lesser curve side most closely resembles the native valve and may optimize outcomes. The proposed AFS Omega configuration described herein reflects this approach.
Conclusions:
Partial, symmetric valve reconstruction combined with hernia repair may reduce fundoplication side effects without compromising efficacy. The Omega configuration represents a conceptual shift from conventional practice. Fundoplication symmetry—beyond the anterior vs posterior partial distinction—should be systematically reported. Intraoperative endoscopic assessment of valve symmetry may further refine surgical technique and guide future innovation.