Overview
Definition:
Dor fundoplication is a surgical procedure performed to correct gastroesophageal reflux disease (GERD) by creating an anterior partial wrap of the gastric fundus around the distal esophagus
It is a type of partial fundoplication, aiming to restore the function of the lower esophageal sphincter (LES) to prevent the retrograde flow of gastric contents into the esophagus.
Epidemiology:
GERD affects approximately 20% of the adult population in Western countries, with a significant proportion experiencing refractory symptoms despite medical management
Surgical intervention is considered for patients with persistent symptoms, complications of GERD, or those preferring definitive treatment
Dor fundoplication is one of the surgical options employed.
Clinical Significance:
For surgical residents and DNB/NEET SS candidates, understanding Dor fundoplication is crucial as it represents a common and effective treatment for severe GERD
Proficiency in its indications, surgical technique, potential complications, and patient selection is vital for comprehensive surgical knowledge and successful examination performance
It directly impacts patient care by offering a durable solution for a prevalent condition.
Indications
Symptomatic Gerd:
Patients with persistent heartburn, regurgitation, or other GERD symptoms that are refractory to optimal medical management (e.g., PPI therapy).
Demonstrated Esophagitis:
Objective evidence of GERD, such as positive 24-hour pH monitoring or esophageal manometry, and significant esophageal damage (e.g., erosive esophagitis, Barrett's esophagus).
Hiatal Hernia:
Often performed in conjunction with the repair of a paraesophageal or sliding hiatal hernia, where the hiatal hernia contributes to GERD.
Patient Preference:
Patients who desire definitive surgical treatment to avoid long-term medication or who have contraindications or intolerance to medical therapy.
Refractory Dysphagia:
In select cases, carefully chosen patients with reflux-induced dysphagia may benefit from surgery, although this is a relative indication.
Preoperative Preparation
Diagnostic Evaluation:
Comprehensive evaluation including upper endoscopy to assess the severity of esophagitis, rule out Barrett's esophagus or malignancy
24-hour esophageal pH monitoring and manometry to confirm GERD and assess LES function.
Medical Optimization:
Patients are typically placed on high-dose proton pump inhibitors (PPIs) for 4-8 weeks preoperatively to suppress acid production and allow for healing of esophageal mucosa.
Nutritional Assessment:
Evaluation of nutritional status, especially if significant weight loss or malnutrition is present due to GERD symptoms.
Patient Counseling:
Detailed discussion with the patient about the risks, benefits, alternatives, and expected outcomes of Dor fundoplication, including potential for postoperative gas bloat, dysphagia, and early satiety.
Anesthesia Considerations:
Pre-anesthetic assessment to identify any comorbidities that may affect anesthetic management.
Procedure Steps
Trocar Placement:
Laparoscopic approach involves placement of multiple trocars in the upper abdomen for instrument insertion, typically using 4-5 ports.
Hiatal Dissection:
Mobilization of the gastric fundus and short gastric vessels
Careful dissection of the crura of the diaphragm to identify and reduce any hiatal hernia.
Esophageal Mobilization:
Creation of a window posterior to the esophagus to allow for passage of the gastric wrap
Avoid excessive esophageal mobilization to prevent injury to the vagal nerves.
Fundoplication Wrap:
The gastric fundus is brought anteriorly and partially wrapped (approximately 180-200 degrees) around the intra-abdominal esophagus, secured with sutures
The wrap should be loose enough to prevent severe dysphagia but tight enough to provide an effective seal.
Mesh Repair:
If a hiatal hernia is present, the crura are approximated with sutures to narrow the diaphragmatic hiatus, often reinforced with a synthetic or biological mesh, particularly in recurrent cases or large hernias.
Postoperative Care
Pain Management:
Adequate analgesia, typically with intravenous or oral opioids, transitioning to NSAIDs as tolerated
Multimodal pain management is encouraged.
Dietary Progression:
Patients are usually started on a clear liquid diet and advanced to a full liquid, then pureed, soft, and eventually regular diet as tolerated, over several days to weeks
Avoid carbonated beverages and gas-producing foods initially.
Early Ambulation:
Encourage early mobilization to reduce the risk of venous thromboembolism and improve pulmonary function.
Monitoring For Complications:
Close observation for signs of bleeding, infection, anastomotic leak, or other surgical complications
Vital signs and urine output are monitored closely.
Discharge Criteria:
Discharge planning includes pain control, ability to tolerate diet, ambulation, and absence of significant surgical complications
Patients are advised to avoid heavy lifting for 4-6 weeks.
Complications
Early Complications:
Bleeding from surgical sites
Injury to adjacent organs (spleen, stomach, esophagus)
Pneumothorax from diaphragmatic dissection
Postoperative nausea and vomiting
Wound infection
Retrosternal pain.
Late Complications:
Dysphagia (difficulty swallowing) is common and can be transient or persistent, requiring dilatation
Gas bloat syndrome (abdominal distension and pain due to inability to belch)
Persistent reflux symptoms if the wrap is inadequate
Diarrhea
Gastric outlet obstruction
Suture dehiscence of the wrap or hiatal repair.
Prevention Strategies:
Meticulous surgical technique, especially during esophageal and diaphragmatic dissection
Proper sizing and tensioning of the fundic wrap
Careful patient selection and preoperative counseling
Gradual dietary advancement postoperatively
Judicious use of mesh for hiatal repair.
Prognosis
Factors Affecting Prognosis:
Success is generally high for selected patients, with symptom relief reported in 80-90%
Factors influencing outcome include accuracy of diagnosis, surgical technique, surgeon experience, and patient adherence to postoperative dietary recommendations.
Outcomes:
Most patients experience significant relief of heartburn and regurgitation
Long-term dependence on PPIs is often reduced or eliminated
However, some patients may still require occasional PPIs or experience recurrent symptoms.
Follow Up:
Regular follow-up is typically scheduled at 1 week, 1 month, 3 months, and 6 months postoperatively, with further follow-up as needed
This allows for monitoring of symptoms, dietary tolerance, and identification of any late complications
Long-term follow-up is important for patients with Barrett's esophagus or other premalignant conditions.
Key Points
Exam Focus:
Dor fundoplication is an anterior partial wrap (180-200 degrees)
Indications include refractory GERD, esophagitis, and hiatal hernia repair
Complications like dysphagia and gas bloat are common
Differentiate from Nissen (360 degrees posterior) and Toupet (270 degrees posterior) fundoplications.
Clinical Pearls:
Adequate esophageal mobilization while preserving vagal nerves is key
Avoid overly tight wraps to minimize dysphagia
Gradual dietary progression is crucial for patient recovery and symptom management
Consider manometry preoperatively to assess esophageal motility disorders which may contraindicate certain wraps.
Common Mistakes:
Inadequate patient selection (e.g., operating on patients with motility disorders or without objective evidence of GERD)
Excessive esophageal mobilization or vagal nerve injury
Creation of a too-tight or too-loose wrap
Failure to address hiatal hernia appropriately
Inadequate postoperative dietary guidance.