Overview

Fundoplication surgery involves reorienting the connection between the esophagus and the stomach, with the goal of controlling gastroesophageal reflux disease (GERD). Reflux can stem from a variety of causes, such as insufficient transmission of food through the esophagus and weakness in the diaphragm that allows the stomach to herniate upward when a person swallows.

With fundoplication, the surgeon cinches up the top section of stomach, called the fundus, against and around the esophagus, like a collar. This improves (or in some cases, re-creates) the valve that keeps stomach acids and other materials from rising into the esophagus.

The surgery is frequently performed laparoscopically through four or five small incisions in the patient’s upper abdomen. With a laparoscopic approach, the surgeon uses special instruments and views the procedure on a video monitor via a miniature camera inserted into the patient. This approach requires more surgical expertise and is less invasive than the open-field procedure – the more conventional approach, historically – which requires a single 6- to 10-inch vertical incision in the patient’s abdomen.

With a laparoscopic approach, patients can anticipate going home within a day or two of surgery. Open-field surgery requires several more postoperative days in the hospital. With either approach, fundoplication leaves patients very satisfied 70% to 80% of the time, according to follow-up studies.

Procedural Details

The surgeon should outline whether the fundoplication will be partial or complete:

  • In a complete, or Nissen, fundoplication, the cinched section of stomach is wrapped fully around the bottom of the esophagus, much like a buttoned shirt collar encircles a neck. This is the standard surgery for treating GERD.
  • Partial fundoplication (Dor procedure) involves wrapping the stomach only partway around the esophagus, or (Toupet procedure) repositioning the stomach against the side of the esophagus. These variants might be preferred when the patient has achalasia, in which the esophagus does not sufficiently move food to the stomach. For these patients, a complete fundoplication could exacerbate the condition.

On the day before surgery, the patient will be on a restricted diet for several hours. On the day of surgery, the patient will be sedated and given a general anesthetic. Without complications, the fundoplication procedure typically takes one to two hours. For a patient whose GERD is related to a paraesophageal hiatal hernia, the weakened diaphragm muscle also would be sutured more tightly to prevent recurrence of upward movement of the esophagus and/or stomach. Post-operative hospitalization will last one to two days for laparoscopy, and early in this period, patients commonly feel nauseated. Medication can help relieve this sensation. Ice chips and liquids such as water, juice, broth – but not soda – will be introduced to the digestive tract first, then soft foods such as yogurt and ice cream.

Effectiveness

Studies suggest that fundoplication satisfactorily reduces or halts GERD symptoms for 80% to 90% of patients. For people undergoing revision fundoplication after a failed procedure, that percentage is closer to 70%. In a recent study of 191 fundoplication patients, nearly 90 percent said they would be willing to undergo the procedure again. Just 1.2% of respondents needed revision surgery.

People who have fundoplication are less likely to need daily medication, and their symptoms are likely to be reduced if medication is halted. Occasionally, with some people who undergo the procedure, new problems emerge, such as gas or bloating, data suggests.

Risks

Potential complications of fundoplication include perforation, abscess or herniation of tissues involved in surgery, excessive bleeding, collapsed lung and pneumonia though these complications are extremely rare. GERD symptoms might recur, though to a lesser degree. Medication might alleviate these new conditions or require surgery to address. Patients might newly experience swallowing difficulty if the wrapped stomach is too constrictive. Rarely, the esophagus dislodges from its collar of stomach tissue.

Risks of bleeding, a negative reaction to anesthesia and post-operative infection emerge with any surgical procedure.