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Fundoplication

Fundoplication surgery involves stitching (or plicating) the top of the stomach (or fundus) around the base of the oesophagus to enhance the lower oesophageal sphincter and reduce reflux. There are various techniques available.

Diagram showing Nissen Fundoplication



Anterior 120º  (or 90º etc)

To reduce the likelihood of inability to belch or vomit, or if the patient has motility problems, a partial wrap is favoured by some surgeons who will usually opt for a 120º wrap around the front (anterior) part of the oesophagus rather than a full 360º Nissen wrap.

Belsey

Dr Ronald Belsey's procdeure was developed about the same time as the Nissen procedure and was the fundoplication of choice before the introduction of laparoscopic techniques. It is similar to a Nissen fundoplication though only performing a 270º wrap of the fundus around the oesophagus.

Since the surgery required access via the thorax rather than the abdomen, its popularity has been succeeded by the Laparoscopic Nissen Fundoplication.

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Collis

The Collis procedure isn't actually a fundoplication but is frequently accompanied by one.

The procedure effectively produces an elongation of the oesophagus beneath the diaphragm into the stomach by sectioning the fundus. This often provides for a more effective Nissen or Belsey wrap which is frequently performed at the same time.

Dor

The Dor procedure is a 90° or 180º anterior wrap frequently employed in conjunction with a Heller's cardiomyotomy as a treatment for achalasia.

Heller's cardiomyotomy

Heller's cardiomyotomy isn't actually a fundoplication but is frequently accompanied by one.

The procedure may be used for patients suffering achalasia. By weakening or cutting the cardial muscles of the lower oesophageal sphincter, foods may pass more easily from the oesophagus into the stomach. However, the opportunity for reflux may then be presented. To reduce that, a Dor partial fundoplication, or the similar Hill fundoplication, may be performed at the same time.

A paper published in the Annals of Surgery in 2006, stated: "Laparoscopic Heller myotomy allows the resolution of the dysphagia with minimal invasion, becoming the treatment of choice among surgeons and even gastroenterologists. The addition of an antireflux procedure to the esophageal myotomy is one of the major aspects of discussion between proponents of the anterior 90° (Dor) and the posterior 270° (Toupet) wrap, while there are some arguments against the routine use of an antireflux procedure." [f-i]

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Nissen

With Hitler's rise to power, Rudolph Nissen, a Jewish doctor, fled his native Germany and, a few years later, Turkey, to America before returning after the war to Switzerland where he developed the gastric fundoplication procedure that now bears his name in 1954 having used similar techniques since 1937. Albert Einstein was one of his patients on whom he performed an operation to cure an aortic aneurysm - a later recurrence of which was to eventually kill him.

Nissen fundoplication has been used over the years on thousands of babies worldwide born with conditions that cause reflux disorders with lifetime results proving efficacy of the treatment.

Initially, inability to burp, belch or vomit was frequently encountered as a side effect but techniques have constantly been revised and developed which have minimised occurrence of these disturbing symptoms.

A Czech study published in 2013 [f-ii] stated ,"Anti-reflux operations are the only procedures which offer the possibility of treating the cause by restoring the anatomic barrier responsible for guarding against irritating effects of gastroduodenal content on the distal esophagus. Total (i.e. 360°) laparoscopic Nissen fundoplication (LNF) is considered the most effective amongst these procedures. Still, controversies related to the indications for anti-reflux surgery are frequently encountered. ...   Laparoscopic Nissen fundoplication, as a result of high effectiveness, represents the method of choice in the treatment of BE in the case of patients who were qualified for surgery."

In the 1990's laparoscopic (keyhole) surgery for fundoplication was introduced. Laparoscopic Nissen Fundoplication (LNF) is now considered the gold standard teratment for reflux against which all other techniques are evaluated.

A study published in Surgical Endoscopy in 2014 reviewed the durability of Laparoscopic Fundoplication over 20 years [f-iii] and concluded, "Long-term results from the early experience with LF are excellent with 94 % of patients reporting only occasional or fewer reflux symptoms at 20-year follow-up. However, 18 % required surgical revision surgery to maintain their results. There is a relatively high rate of daily dysphagia but 90 % of patients are happy to have had LF." 

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Rossetti

Dr. Mario Rossetti, a pupil of Rudolph Nissen, introduced a modification of the surgery in 1972, known as Nissen-Rossetti fundoplication, which utilises only the anterior wall of the fundus. Use of this modification is widespread.
A 2006 review of the procedure states, "When compared with other antireflux procedures, total fundoplication is the most effective barrier against reflux. Nissen-Rossetti, in particular, achieves this goal without the need to resection the short gastric vessels." [f-iv]

Toupet 

Unlike other partial wraps, that developed by André Toupet in 1963 is a 270° posterior wrap of the fundus around the back of the oesophagus designed to reduce dysphagia and the occurrence of a hiatus hernia.

A paper published in International Surgery in 2003, stated, "for patients in whom esophageal peristalsis is documented to be weak preoperatively, use of a partial wrap, or Toupet procedure, has often been used as an alternative to lessen the potential for postoperative dysphagia" and concluded, "We recommend its selective use in patients with preoperative esophageal hypomotility who are undergoing laparoscopic antireflux surgery." [f-v]

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Footnotes

 Although the main variations of fundoplication surgery have been included above, there are and have been other modifications to the Nissen fundoplication not described here, including those performed by Drs Phillip Donahue,  Pearson and Henderson, Orringer and Sloan, Thomas Bombeck, Lucian Hill and Thomas DeMeester.

The Medscape overview of fundoplication (2014) says, “When comparing the efficacy of antireflux surgery with medical treatment, there has been considerable debate. A systematic review concluded similar efficacy between these 2 treatment options. Some recent literature suggests that long-term outcomes from antireflux surgery may be superior to medical treatment. The latest guidelines from the American College of Gastroenterology indicate, "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). In appropriately selected patients, laparoscopic reflux surgery may be more cost effective than lifelong medical treatment.” [f-vi]

See Appendix 1 for the NICE Options Grid to aid patient discussion regarding fundoplication vs medication.

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