Background
Dr Rudolf Nissen (1896-1981) described the first fundoplication in the 1950s for treatment of severe reflux esophagitis. His original procedure created a 360º wrap of the fundus of the stomach around the esophagus by plicating both the anterior and posterior walls of the gastric fundus around the lesser curvature. Although Nissen fundoplication has been modified many times, this procedure remains the preferred surgical treatment of esophageal reflux.
Indications
Patients may present with typical or atypical symptoms of gastroesophageal reflux disease (GERD). Typical symptoms, also known as esophageal GERD symptoms, include heartburn, regurgitation, waterbrash, and dysphagia. Reflux can lead to complications, including esophagitis, ulcers, esophageal strictures, and Barrett esophagus.
Atypical symptoms, also referred to as extraesophageal symptoms, include sore throat, dental erosions, cough, asthma, dysphonia, laryngitis, laryngeal stenosis, chronic cough, bronchitis, pulmonary fibrosis, laryngeal polyps, laryngeal cancer, and chest pain.
Empiric medical therapy, using proton pump inhibitors (PPIs), for GERD is typically initiated with complaints of dyspepsia. [1] The literature shows different levels of support when comparing the efficacy of antireflux surgery with that of medical treatment. A systematic review found these two treatment options to be similar in efficacy. [2] Studies in the literature have suggested that long-term outcomes from antireflux surgery may be superior to those from medical treatment. [3, 4, 5]
However, Emken et al, in a randomized prospective study comparing the effect of antireflux surgery with PPI therapy in terms of the effect on lower esophageal sphincter (LES) function and esophageal acid exposure in patients with chronic GERD, found that at 10 years, there was no significant difference in acid reflux control. [6] A 2011 UK randomized controlled trial revealed that antireflux surgery may be more cost-effective than PPI use in the long term. [7] A 2021 meta-analysis found that fundoplication is more effective than PPI therapy for treating GERD and does not significantly increase the risk of adverse events. [8]
Further testing is indicated in patients who have ongoing symptoms despite appropriate medical management, warning symptoms (eg, dysphagia, anemia, or guaiac-positive stools), or atypical symptoms, as well as in any patient whose diagnosis remains unclear. Diagnostic testing is also indicated before surgical intervention. Patients with typical symptoms of GERD should have at least one additional positive objective test for diagnostic purposes. Patients with atypical symptoms should have at least two positive objective tests for diagnosis.
Indications for an antireflux operation include the following [9] :
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Failure of medical management
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Complications of GERD (eg, Barrett esophagitis or peptic stricture)
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Patient preference (eg, desire to discontinue medical therapy because of quality-of-life concerns, financial concerns, or inability to tolerate medication)
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Extraesophageal manifestations (asthma, hoarseness, cough, chest pain, aspiration)
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Juvenile esophagitis that is of long duration without spontaneous remission or is refractory to medical management, esophagitis, failure to thrive, or pulmonary compromise
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Mixed and paraesophageal hernia
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Recurrent reflux or complications after previous antireflux surgical therapy
Currently, a laparoscopic approach is used for most antireflux procedures; it is generally considered to be associated with lower morbidity and mortality, shorter hospital stays, and lower healthcare costs. [10] Indications for an open approach include the following:
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Lack of expertise in or equipment for laparoscopic surgery
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Patient preference
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Intraoperative difficulties during laparoscopic fundoplication necessitating conversion
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Reoperation following previous laparoscopic or open procedures
Contraindications
Fundoplication should be avoided in morbidly obese patients (body mass index [BMI] >35 kg/m2) because of the high failure rates. Rather than fundoplication, gastric bypass should be considered in these patients. Concerns have been expressed about bypass in patients who have previously undergone nonbariatric foregut procedures such as Nissen fundoplication, but despite the increased technical difficulty and the higher perioperative morbidity, long-term symptom resolution and robust weight loss can be achieved. [11]
Open Nissen fundoplication should also be avoided in patients with esophageal motility disorders such as achalasia.
Outcomes
Mortality after open Nissen fundoplication is extremely rare. Immediately after the procedure, patients often experience abdominal fullness, mild dysphagia, or even postprandial discomfort. These symptoms are consistent with edema formation at the cardia. This often resolves with small meals and prokinetic drugs. A liquid diet should be started postoperatively to assist patients with this common transient dysphagia. Pneumothorax or surgical emphysema may occur and is likely related to excessive hiatal dissection.
If severe postoperative pain, intractable emesis, fever, tachycardia, or leukocytosis occurs in the immediate postoperative period, perforation of the esophagus or stomach should be suspected. Disruption of the fundoplication may also cause similar symptoms. Acute paraesophageal herniation is an uncommon complication. An upper gastrointestinal (GI) series should be obtained immediately.
Injury to surrounding structures (eg, vagus nerves, spleen, or other abdominal viscera) is possible. Hemorrhage, ileus, urinary retention, wound infection, and dehiscence have also been described.
Gas bloat syndrome is described as fullness and or pain due to the sensation of intestinal gas. Although rare, it can be troublesome to accurately diagnose and treat. The exact pathophysiology is unknown. However, difficulty belching, combined with subconscious aerophagia and transient or permanent delayed gastric emptying, leads to increased intraluminal gas, creating the uncomfortable sensation.
Patients are often counseled on dietary changes, including avoidance of carbonated beverages and use of straws. Mild symptoms may be medically treated with simethicone, metoclopramide, or erythromycin. Rarely, severe symptoms may necessitate surgical intervention. If symptoms are thought to be due to gastroparesis, a pyloroplasty can be considered. Other surgical options include conversion of a 360º fundoplication to a partial fundoplication.
Ongoing dysphagia that persists for longer than 12 weeks postoperatively indicates the need for further evaluation. Dysphagia may be due to wrap failure. Wrap failure includes disruption, slippage, herniation into the chest, or a wrap that is too tight. Dysphagia that presents late may be due to excessive scar formation or wrap migration. A barium swallow should be obtained to assess the fundoplication. Approximately 6-12% of patients may require dilation. [12]
To achieve consistently excellent outcomes and avoid the above complications, the esophageal surgeon should have a thorough understanding of the pathophysiology of each patient’s disease process. He or she should also be familiar with several modifications (eg, Rossetti) and other partial fundoplications that can be performed to meet the needs of the patient and goals of the operation. A surgeon’s particular training and application of technique, along with patient selection, will determine the overall outcome.
Some patients may require redo Nissen fundoplication because of Nissen failure, ongoing symptoms, or recurrent symptoms. The need for recurrent surgery is less in patients undergoing open Nissen fundoplication than it is in those undergoing the equivalent laparoscopic operation. [13] The lower incidence of recurrence after open fundoplication has been observed in pediatric as well as adult patients. [14, 15, 16]
Other late postoperative complications include small-bowel obstruction due to adhesions and hernias.
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Rossetti-Nissen modified fundoplication.
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Nissen fundoplication.
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Toupet partial fundoplication.
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Hiatal dissection. Esophagus is encircled and retracted anteriorly, exposing posterior hiatus for dissection.
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Hiatal repair. Sutures should be placed from posterior to anterior.
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Hiatal repair.
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Anterior wall of gastric fundus is passed behind esophagus with atraumatic Babcock forceps.
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Rossetti-Nissen fundoplication.
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Anatomy of lower esophageal sphincter.
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Original Nissen fundoplication, as described by Dr Rudolf Nissen.
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Severe distal reflux esophagitis, as seen via esophagogastroduodenoscopy. Video courtesy of Dawn Sears, MD, and Dan C Cohen, MD, Division of Gastroenterology, Scott & White Healthcare.
