Laparoscopic Nissen Fundoplication

The most common procedure used to treat GERD, Nissen fundoplication reconstructs the area of the Lower Esophageal Sphincter (LES) to prevent acid from washing into the esophagus. This is in contrast to medical therapy which alters the fluid that washes into the esophagus making the fluid less injurious to the esophagus.

Normal Anatomy
(Click to view a larger image of the normal anatomy)

Incisions
Using a scope that is inserted through a small (~1/2 inch) incision, and four additional incisions (one 1/2 inch and three 1/4 inch), the Gastroesophageal Junction is reconstructed to create a barrier preventing stomach acid from refluxing into the esophagus.

The wrap is sutured in place completing the operation. The procedure typically lasts about one hour.

• Most patients can go home the day of surgery, others spend the night in the hospital for observation.
  
• Physical recovery is similar to laparoscopic cholecystectomy with most patients able to tolerate light activity immediately and vigorous activity in one to two weeks.
  
• The average patient takes about one week off from work although this is variable depending on the type of employment.
  
• The largest issue in terms of recovery has to do with return to normal diet which usually takes two to six weeks. After surgery, patients are given a Post Nissen diet to guide their return to a normal diet.

Results
In properly selected patients, the surgery is successful in improving or eliminating heartburn and regurgitation in greater than 90% of patients.

Patients notice improvement in direct symptoms such as heartburn and regurgitation immediately after surgery. Indirect symptoms such as asthma, hoarseness, dysphagia, cough, globus, and esophageal spasm often take weeks to months to improve. These symptoms are not as reliably improved after surgery as the direct symptoms of GERD. Indirect symptoms also do not respond as well to medical treatment.

In most patients this result is durable and lasting with multiple studies showing a high degree of patient satisfaction many years after the procedure. Recently some have questioned the long term success of anti-reflux surgery. A recent article published in Journal of the American Medical Association (JAMA) reported that 62% of a group of VA patients who underwent open surgery ten years ago took anti-secretory medications. This study is often quoted to argue against the use of anti-reflux surgery. When this study is closely evaluated the following points are telling:

• The study group was “uncontrolled”, meaning that the prescribing of these medications was outside any protocol and in fact only the minority had any testing to determine if they had recurrent GERD.
• When the 62% of patients who were taking medications, had these medications stopped, there was no change in their symptoms. This calls into question whether these drugs were appropriately prescribed or necessary.
• When surgical patients were asked about their satisfaction with the procedure:
  72% very satisfied
  14% satisfied
  10% dissatisfied
  3% very dissatisfied
• 89 percent of surgical patient asked if “they would do it all over again” would have surgery again!

Risks
Failure to completely resolve symptoms:variable depending on symptoms
Dysphagia (Difficulty swallowing): ~ 2%
Gas bloat syndrome: ~ 2%
Conversion to open procedure: ~ 1%
Injury to nearby structures: ~ 1%
Bleeding and pneumothorax: rare

Is laparoscopic anti-reflux surgery better than open surgery?
Fundoplication has been done as an open surgery (through a ~10 inch incision) for almost 50 years. Over this long period of time this procedure, when performed by surgeons with extensive experience with the procedure, has proven to be a highly successful durable treatment for GERD. In the last 10 years the application of minimally invasive techniques has allowed this procedure to be done with a significantly shorter hospitalization, less pain, and quicker recovery. Dr. Fusco also feels that the quality of the procedures performed has improved for two reasons. Firstly in most situations the view of the operative area is better laparoscopically. Secondly, since fewer surgeons have been trained to perform these advanced laparoscopic techniques, the net effect is that there is a concentration of a greater amount of experience with the procedure in the fewer surgeons who have dedicated themselves to the treatment of GERD.

Dr. Fusco also offers the Esophyx procedure to treat acid reflux. The Esophyx procedure is a Natural Oriface (NOTES) procedure where the lower esophageal sphincter is reconstructed using an endoscope and NO INCISIONS.

University of Pittsburgh: Overview on Laparoscopic Anti-reflux surgery.
Surgery Channel: Good general overview of the surgery. Also has a fair medical glossary
Heartburn Help Website: Site sponsored by Ethicon
Good scientific overview of reflux surgery
www.endogastricsolutions.com : makers of the esophyx device