Nissen fundoplication: still the gold standard?

Introduction

Gastroesophageal reflux disease (GERD) affects almost 20% of the population in the United States. Today, proton pump inhibitors (PPIs) are the most frequently prescribed drugs, with an estimated cost of 10 billion dollars per year. Although these medications control heartburn in the majority of patients, other symptoms such as regurgitation and respiratory symptoms often are not controlled, particularly in patients with large hiatal hernias. In addition, potential side effects of these medications have been identified: from osteoporosis secondary to decreased absorption of calcium to nephritis, from pneumonia to major adverse cardiac events. Furthermore, PPI should not be prescribed for patients that have coronary stents and take clopidogrel bisulfate as they counteract its antiplatelet activity.

In these patients, a properly performed laparoscopic fundoplication allows control of both esophageal and extra-esophageal symptoms, avoiding life-long medical therapy.

Three elements are important for the performance of a successful fundoplication: (I) a comprehensive preoperative work-up; (II) correct indications for the operation, and (III) respect of the key technical elements.

Pre-operative work-up

In 2013, a panel of expert gastroenterologists and surgeons published an evidence and experienced-based consensus that recommended the following tests before proceeding with anti-reflux surgery (1):

• Symptomatic evaluation: this step identifies typical/esophageal symptoms (heartburn, regurgitation, and dysphagia) and atypical/extra-esophageal symptoms (cough, hoarseness, and enamel erosion). A symptomatic evaluation alone should never be considered enough to plan an operation. Many studies have shown that the presence of symptoms alone, even for typical symptoms such as heartburn, has a low accuracy and leads to a wrong diagnosis of GERD in 30% to 50% of patients (2-4) A good response to PPI is considered an important prognostic factor for the success of a fundoplication (5) whereas lack of response—usually labeled as “refractory GERD”—should raise the suspicion that the symptoms are caused by a different disease (2,4);
• Barium swallow: to define the anatomy of the gastroesophageal junction and the presence, size, and type of a hiatal hernia;
• Upper endoscopy: to determine presence and severity of esophageal mucosal damage;
• Esophageal manometry: to assess quality of esophageal peristalsis, rule out achalasia, and determines the position of the lower esophageal sphincter (LES) for placement of the catheter for pH monitoring;
• Ambulatory pH monitoring: this study is considered the gold standard for the diagnosis of GERD, as it establishes the presence of abnormal reflux and the temporal correlation between symptoms and episodes of reflux;
• Gastric emptying studies and impedance pH should be considered in very few selected patients (6).

Overall, the presence of heartburn, a good response to PPIs, and pathological reflux as shown by pH monitoring are important predictors of a successful outcome of a fundoplication (5).

Indications for the operation

The operation is indicated when patients experience complications of PPI therapy, do not want to take medications for the rest of their lives, or do not have complete control of their symptoms, particularly when regurgitation persists and it is associated with cough or episodes of aspiration pneumonia. Caution must be exerted when there is a complete lack of response to PPI therapy, and patients are labeled as having “refractory GERD”. A complete work-up is of paramount importance to ensure that the symptoms are not caused by other esophageal disorders such as achalasia or eosinophilic esophagitis or by other gastrointestinal diseases such as irritable bowel syndrome or cholelithiasis (2-4). As of today, we do not have evidence suggesting that a fundoplication can halt the progression from Barrett’s metaplasia to high-grade dysplasia and cancer. Therefore, the indications for anti-reflux surgery are for control of symptoms like any other patient.

Key technical elements

The term Nissen fundoplication is widely used to describe a 360º or total fundoplication. Today we feel that it is time to abandon the eponyms such as Nissen, Guarner, Toupet, Hill, and focus on the key technical elements that allow the performance of a fundoplication that controls effectively reflux and lasts over time.

• Extent of mobilization. Dissection in the mediastinum is particularly important when a hiatal hernia is present. In addition, we do divide the short gastric vessels to create a tension free fundoplication using the anterior and posterior wall of the stomach;
• Location of gastroesophageal junction after dissection. About 3–4 cm of esophagus must be present below hiatus;
• Closure of hiatus with non-absorbable sutures. This is a key step as it is known that the diaphragm has a synergistic action with the LES, particularly protecting against episodes of reflux due to bending or cough;
• Size of bougie. The use of the bougie decreases the incidence of postoperative dysphagia (7). We routinely use a 56F to 60F bougie. Before inserting it, the temperature probe and the orogastric tube are removed, as well as any instrument. It is key to avoid angulation of the gastroesophageal junction, the most vulnerable area for a perforation;
• The stomach is passed behind the esophagus, and a shoe-shine maneuver is performed to avoid a redundant fundoplication built with the body rather than the fundus of the stomach. A 360º fundoplication is created by placing three stitches of non-absorbable material at 1 cm intervals to approximate the right and left side of the fundoplication. In patients with very severe abnormalities of peristalsis such as achalasia or connective tissue disorders, a partial fundoplication is the procedure of choice, as it is associated with a lower incidence of postoperative dysphagia (6,8).

Although transient dysphagia is common in the initial weeks after fundoplication, long-term dysphagia is rare. As previously reported, the use of a bougie decreases the incidence of postoperative dysphagia. Patterson showed that the incidence of long-term severe postoperative dysphagia was 5% when a bougie was used, but was 14% when it was not used (7). In addition, transection of the short gastric vessels allows a tension-free fundoplication, with a lower incidence of postoperative dysphagia (9). The presence of dysphagia preoperatively is the best predictor of postoperative dysphagia (10).

Dr. Dallemagne reported the 10-year follow-up of 100 consecutive patients after laparoscopic fundoplication (11). Ninety-three per cent of patients were doing well after Nissen fundoplication. Excellent results were also recently reported among 2,655 patients who underwent laparoscopic fundoplication in Sweden between 2005 and 2014. At median follow-up of 5.6 years, 82.3 were symptom free and off medications (12). In the remaining patients it was not clear if symptoms and use of PPIs were really due to recurrent reflux (13).

In conclusions, laparoscopic Nissen fundoplication is an effective and long-lasting treatment for GERD. Its success is based on a careful evaluation and patient selection, and on an operation that respects the key technical elements that have been already identified. Considering the proven safety and effectiveness of laparoscopic anti-reflux surgery, new endoscopic and laparoscopic anti-reflux procedures should be rigorously studied and cautiously adopted.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editor (Luigi Bonavina) for the series “Gastroesophageal Reflux Disease” published in Annals of Esophagus. The article has undergone external peer review.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/aoe.2018.07.03). The series “Gastroesophageal Reflux Disease” was commissioned by the editorial office without any funding or sponsorship. FS serves as an unpaid editorial board member of Annals of Esophagus from Aug. 2018 to Jul. 2020. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Jobe BA, Richter JE, Hoppo T, et al. Preoperative diagnostic workup before antireflux surgery: an evidence and experience-based consensus of the Esophageal Diagnostic Advisory Panel. J Am Coll Surg 2013;217:586-97. [Crossref] [PubMed]
2. Patti MG, Diener U, Tamburini A, et al. Role of esophageal function tests in diagnosis of gastroesophageal reflux disease. Dig Dis Sci 2001;46:597-602. [Crossref] [PubMed]
3. Chan K, Liu G, Miller L, et al. Lack of correlation between a self-administered subjective GERD questionnaire and pathologic GERD diagnosed by 24-h esophageal pH monitoring. J Gastrointest Surg 2010;14:427-36. [Crossref] [PubMed]
4. Bello B, Zoccali M, Gullo R, et al. Gastroesophageal reflux disease and antireflux surgery-what is the proper preoperative work-up? J Gastrointest Surg 2013;17:14-20; discussion p. 20.
5. Campos GM, Peters JH, DeMeester TR, et al. Multivariate analysis of factors predicting outcome after laparoscopic Nissen fundoplication. J Gastrointest Surg 1999;3:292-300. [Crossref] [PubMed]
6. Broeders JA, Roks DJ, Ahmed Ali U, et al. Laparoscopic anterior 180-degree versus nissen fundoplication for gastroesophageal reflux disease: systematic review and meta-analysis of randomized clinical trials. Ann Surg 2013;257:850-9. [Crossref] [PubMed]
7. Patterson EJ, Herron DM, Hansen PD, et al. Effect of an esophageal bougie on the incidence of dysphagia following nissen fundoplication: a prospective, blinded, randomized clinical trial. Arch Surg 2000;135:1055-61; discussion 1061-2. [Crossref] [PubMed]
8. Cai W, Watson DI, Lally CJ, et al. Ten-year clinical outcome of a prospective randomized clinical trial of laparoscopic Nissen versus anterior 180(degrees) partial fundoplication. Br J Surg 2008;95:1501-5. [Crossref] [PubMed]
9. Hunter JG, Swanstrom L, Waring JP. Dysphagia after laparoscopic antireflux surgery. The impact of operative technique. Ann Surg 1996;224:51-7. [Crossref] [PubMed]
10. Herron DM, Swanström LL, Ramzi N, et al. Factors predictive of dysphagia after laparoscopic Nissen fundoplication. Surg Endosc 1999;13:1180-3. [Crossref] [PubMed]
11. Dallemagne B, Weerts J, Markiewicz S, et al. Clinical results of laparoscopic fundoplication at ten years after surgery. Surg Endosc 2006;20:159-65. [Crossref] [PubMed]
12. Maret-Ouda J, Wahlin K, El-Serag HB, Lagergren J. Association Between Laparoscopic Antireflux Surgery and Recurrence of Gastroesophageal Reflux. JAMA 2017;318:939-46. [Crossref] [PubMed]
13. Patti MG, Schlottmann F. Recurrence of Reflux After Laparoscopic Antireflux Surgery. JAMA 2018;319:82-3. [Crossref] [PubMed]