Fundoplication Surgery

Nissen Fundoplication procedureIn essence, fundoplication procedures work by wrapping a part of the stomach around the lower oesophageal sphincter (or LOS) to prevent reflux.  The LOS consists of a layer of muscle around the lower oesophagus which acts as a one-way valve. In normal individuals the LOS allows food and liquid to pass into the stomach, but works as a barrier to stomach contents moving upwards (see diagram). In patients with GORD, the LOS is incompetent and allows stomach acid to leak into the oesophagus (see diagram).  

There are several types of fundoplication, the best known of which is the Nissen (see diagram above), providing a total (360°) wrap. Partial fundoplications include the Belsey (270°), Dor fundoplication (180-200°) or Toupet fundoplication (270°), which may be recommended in certain clinical situations.  

In general, the fundoplication is considered to be a safe and effective procedure with a long-term success rate of 85-90% at 10-years.  However, there can be significant problems with the surgery, including dysphagia (difficulty swallowing); gas-bloat syndrome; damage to the vagus nerve and a recurrence of reflux symptoms.  Note that it is also difficult to vomit or to belch (burp) after a fundoplication.

Dysphagia

Dysphagia is one of the most important post-fundoplication symptoms. Most patients have some degree of dysphagia in the postoperative period, but this can usually be managed by giving liquids and a soft diet for the first few weeks.   However, severe and persistent dysphagia occurs in 3% to 5% of patients.  This is usually due to a surgical complication, such as the wrap being too restrictive.  

Gas-bloat syndrome

This is exactly what it says; an accumulation of gas in the stomach and small intestine, due to the inability of the patient to expel air through belching.  It can cause quite severe cramping and abdominal pain and is very common after Nissen fundoplication with perhaps 40% of patients affected.  The problem is usually self-limiting and tends to subside after 4-5 weeks, though in some individuals it may persist.  

Vagus nerve damage

Accidental injury to the vagus nerve (branches of which are close to the point of the wrap) can occur during the fundoplication.  Patients may develop symptoms of nausea, bloating and diarrhea.  The problem can usually be managed successfully with diet and medication, but in a small proportion of patients symptoms may be persistent.  

Recurrence of reflux

A recurrence of reflux symptoms after surgery may be the result of too limited a wrap, leaving acid-secreting stomach tissue above the wrap.  A recent long-term study found that recurrence of symptoms was much more common after a 180° wrap when compared with the full Nissen procedure.  However, the limited wrap has a lower risk of dysphagia when compared with the Nissen fundoplication.  

We receive a number of enquiries from patients who, following unsatisfactory results from fundoplication surgery, wish to be considered for a LINX™ procedure. Tests are to be undertaken to study the possibility of implantation of the LINX™ device in fundoplication patients but it is unlikely that the eligibility criteria for LINX™ device will include fundoplication patients in the very near future.

Conclusion

In experienced hands, the Nissen fundoplication is an effective anti-reflux procedure, with generally good long-term results.  However, complications such as dysphagia are not unusual and may be difficult to manage.  Partial fundoplication has a lower risk of dysphagia, but may be less successful in controlling reflux symptoms compared with the standard Nissen procedure. 

References

  1. Broeders JA, Broeders EA, et al.  Objective Outcomes 14 Years After Laparoscopic Anterior 180-Degree Partial Versus Nissen Fundoplication: Results From a Randomized Trial. Ann Surg 2012 Nov 30. [Epub ahead of print].
  2. Rosemurgy AS et al.  Gastroesophageal Reflux Disease.  Surg Clin North Am 2011; 91:1015-1029
  3. Dallemagne B, Weerts J et al.  Clinical results of laparoscopic fundoplication at ten years after surgery.  Surg Endosc 2006; 20:159-165

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