Laparoscopic Nissen Fundoplication

Updated: May 18, 2016
  • Author: F Paul (Tripp) Buckley, III, MD, FACS; Chief Editor: Kurt E Roberts, MD  more...
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Overview

Background

Laparoscopic Nissen fundoplication is now considered the standard surgical approach for treatment of severe gastroesophageal reflux disease (GERD). [1] GERD is increasingly prevalent and costly, and it may affect as much as 20% of the US population. [2]

The pathophysiology of GERD is not due to acid overproduction but rather mechanical dysfunction centered around the lower esophageal sphincter (LES). Furthermore, the mainstay of GERD treatment, proton pump inhibitors (PPIs), have come under scrutiny because of worrisome side effects. [3, 4] Laparoscopic magnetic sphincter augmentation of the LES has been proposed as an additional surgical option. Like Nissen fundoplication, it relies on 360° buttressing of the LES, but it may cause fewer long-term adverse effects. [5]

Dr Rudolf Nissen (1896-1981) described the first fundoplication in the 1950s for treatment of severe reflux esophagitis. His original procedure used a 360° wrap of the fundus of the stomach around the esophagus by plication of both the anterior and posterior walls of the gastric fundus around the lesser curvature. Although the standard Nissen fundoplication has been modified many times, laparoscopic Nissen fundoplication is now considered the standard surgical approach for treatment of GERD. [1]

There has been considerable debate about the relative efficacies of antireflux surgery and medical treatment. A systematic review concluded that the two treatment approaches were of similar efficacy. [6] Some of the literature suggests that long-term outcomes from antireflux surgery may be superior to those of medical treatment. [7, 8]

Guidelines from the American College of Gastroenterology (ACG) indicate that "surgical therapy is as effective as medical therapy for carefully selected patients with chronic GERD when performed by an experienced surgeon" (strong recommendation; high level of evidence). [9] In appropriately selected patients, laparoscopic reflux surgery may be more cost-effective than lifelong medical treatment. [10, 11]

Laparoscopic Nissen fundoplication may have advantages over the traditional open approach, including improved cosmesis, reduced morbidity, shorter hospital stay, decreased respiratory complications, and faster recovery. [12, 13, 14] However, the laparoscopic approach may be associated with longer operating times. [13] With respect to subjective symptoms, long-term outcomes after laparoscopic Nissen fundoplication are comparable to those after open surgery. [15, 16, 17] Currently, the laparoscopic approach is favored over an open approach unless it is specifically contraindicated.

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Indications

Indications for laparoscopic antireflux surgery include the following [18, 9] :

  • Failure of medical management
  • Need for long-term medical therapy
  • Complications of GERD (eg, Barrett esophagus or peptic stricture)
  • Patient preference (eg, desire for discontinuance of medical therapy because of quality-of-life concerns, financial concerns, or intolerance to medication)
  • Extraesophageal manifestations (eg, asthma, hoarseness, cough, chest pain, aspiration)
  • Juvenile esophagitis of long duration without spontaneous remission or refractory to medical management, esophagitis, failure to thrive, or pulmonary compromise
  • Mixed and paraesophageal hernia
  • Recurrent reflux or complications after previous antireflux surgical therapy

The 2013 ACG guidelines note that surgery is a treatment option for long-term therapy in GERD patients and that it is as effective as medical therapy in carefully selected patients when performed by an experienced surgeon. [9]

Magnetic sphincter augmentation

In 2012, the US Food and Drug Administration (FDA) approved the LINX Reflux Management System (Torax Medical, St Paul, MN), a magnetic sphincter augmentation system designed to support the LES in much the same way as a fundoplication. Unlike a fundoplication, the device is dynamic, being made up of multiple interlinked titanium-coated rare-earth magnets. Results from clinical trials have been promising, with excellent results relative to control of reflux and with fewer of the adverse effects (eg, dysphagia, gas-bloat) that may accompany a traditional fundoplication. Additionally, the safety profile seems to be very good. [19, 20]

In some cases, removal of the device may become necessary. A laparoscopic technique for accomplishing this has been described. [21]

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Contraindications

Contraindications to laparoscopic antireflux surgery include the following:

  • Surgeon inexperience
  • Inability to tolerate general anesthesia
  • Inability to tolerate a laparotomy
  • Advanced cardiopulmonary disease
  • Uncorrectable coagulopathy
  • Portal hypertension

Relative contraindications include previous upper abdominal surgery and severely shortened esophagus. Fundoplication (open or laparoscopic) should be avoided in the morbidly obese patients (body mass index greater than 35 kg/m2) because of the high failure rates. Instead of fundoplication, gastric bypass should be considered in these patients. Nissen fundoplication should also be avoided in patients with esophageal motility disorders such as achalasia.

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