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 due not to acid overproduction but, rather, to 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, 6]
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. [7] Some of the literature has suggested that long-term outcomes from antireflux surgery may be superior to those of medical treatment. [8, 9] In appropriately selected patients, laparoscopic reflux surgery may be more cost-effective than lifelong medical treatment. [10, 11]
The 2022 guidelines from the American College of Gastroenterology (ACG) [12] stated that "modern medical antireflux therapy and laparoscopic fundoplication seem to have similar efficacy in healing the symptoms and endoscopic signs of GERD.... Clearly, antireflux surgery is not a permanent cure for GERD in all patients as it was once touted to be, and the operation occasionally can have severe adverse effects. Nevertheless, most patients obtain long-term benefit from fundoplication, and patient satisfaction with successful surgery seems to be greater than that for chronic medical therapy."
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. [13, 14, 15] ; however, it may also be associated with longer operating times. [14] With respect to subjective symptoms, long-term outcomes after laparoscopic Nissen fundoplication are comparable to those after open surgery. [16, 17, 18] Currently, the laparoscopic approach is favored over an open approach unless it is specifically contraindicated.
Robotic-assisted fundoplication was developed as a minimally invasive alternative to conventional laparoscopic fundoplication. A long-term (12 y) study by Lang et al found no significant differences between the two approaches with respect to postoperative symptoms, quality of life, or treatment failure; both were associated with a high rate of patient satisfaction. [19]
A transoral incisionless fundoplication (TIF) procedure has been developed [20] and is considered to be an acceptable option in selected patients [21] ; however, it has not been shown to be superior to laparoscopic Nissen fundoplication. [22]
Indications
Indications for laparoscopic antireflux surgery include the following [12, 23] :
-
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
For pediatric patients, the 2018 guidelines from the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) stated that antireflux surgery, including fundoplication, should be considered in infants and children who have GERD and one or more of the following [24] :
-
Life-threatening complications (eg, apnea) after failure of optimal medical treatment
-
Symptoms refractory to optimal therapy, after appropriate evaluation to exclude other underlying diseases
-
Chronic conditions (eg, neurologic impairment, cystic fibrosis) with a significant risk of GERD-related complications
-
Need for chronic pharmacotherapy for control of signs or symptoms of GERD
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 (MSA) 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 initial clinical trials were promising, with a good safety profile, excellent control of reflux, and fewer of the adverse effects (eg, dysphagia, gas-bloat) that may accompany traditional fundoplication. [25, 26, 6] Early long-term data are also promising. [27]
In some cases, removal of the device may become necessary. A laparoscopic technique for accomplishing this has been described. [28]
Contraindications
Contraindications for 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 morbidly obese patients (body mass index [BMI] >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.
Outcomes
A double-blind randomized clinical trial by Analatos et al compared long-term (>15 y) outcomes of posterior partial fundoplication (PF; 270°) vs total fundoplication (TF; 360°) with respect to mechanical complications, reflux control, and patient quality of life. [29]
-
Laparoscopic Collis-Nissen fundoplication. Video courtesy of Society of American Gastrointestinal and Endoscopic Surgeons (SAGES).
-
Nissen-Rossetti modified fundoplication.
-
Lower esophageal sphincter.
-
Original Nissen fundoplication as described by Dr Rudolf Nissen.
-
Port placement for laparoscopic Nissen fundoplication.
-
Laparoscopic Nissen fundoplication. View of hiatus after insertion of liver retractor.
-
Laparoscopic Nissen fundoplication. Division of gastrohepatic ligament.
-
Laparoscopic Nissen fundoplication. Penrose drain is placed around esophagogastric junction to retract it anteriorly and laterally to allow improved visualization of hiatus.
