Overview
Definition:
Nissen fundoplication is a laparoscopic or open surgical procedure performed to treat gastroesophageal reflux disease (GERD) by wrapping the upper part of the stomach (fundus) around the lower esophagus
This valve-like structure aims to strengthen the lower esophageal sphincter (LES) and prevent acid reflux back into the esophagus
It is considered the gold standard for surgical management of severe or refractory GERD.
Epidemiology:
GERD affects approximately 10-20% of the population in Western countries, with a significant portion experiencing symptoms refractory to medical management
Nissen fundoplication is performed on thousands of patients annually worldwide, making it a common surgical procedure for surgeons in training.
Clinical Significance:
Effective management of GERD is crucial to prevent long-term complications such as esophagitis, esophageal strictures, Barrett's esophagus, and esophageal adenocarcinoma
Nissen fundoplication offers a durable solution for patients with severe GERD, improving quality of life and reducing the risk of these sequelae, thus it is a vital skill for surgical residents preparing for their board examinations.
Indications
Indications For Surgery:
Failure of maximal medical therapy for at least 6-12 months
Symptomatic GERD with objective evidence of reflux (e.g., pH monitoring, endoscopy)
Recurrent aspiration pneumonia secondary to GERD
Esophageal stricture or Barrett's esophagus in select patients
Patients desiring definitive treatment
Young patients with long-standing GERD to prevent long-term complications.
Contraindications:
Severe comorbidities precluding surgery
Significant motility disorders of the esophagus (e.g., achalasia)
History of multiple abdominal surgeries with extensive adhesions
Uncontrolled peptic ulcer disease
Patient refusal or inability to comply with postoperative care.
Preoperative Preparation
History And Physical:
Detailed history focusing on GERD symptoms, duration, triggers, response to medication, and impact on quality of life
Review of previous investigations (endoscopy, manometry, pH monitoring)
Physical examination to assess overall health and identify any surgical contraindications.
Diagnostic Workup:
Upper endoscopy to assess for esophagitis, strictures, Barrett's esophagus, and rule out malignancy
Esophageal manometry to evaluate LES pressure and esophageal motility
24-hour esophageal pH monitoring to objectively document reflux episodes and correlate with symptoms
Barium swallow may be used to assess anatomical abnormalities.
Medical Optimization:
Optimization of proton pump inhibitor (PPI) therapy prior to surgery
Smoking cessation
Weight loss if obese
Dietary modifications
Counseling on surgical risks and benefits, and importance of postoperative adherence.
Procedure Steps
Laparoscopic Nissen:
Positioning the patient supine with legs abducted
Creation of pneumoperitoneum
Placement of trocars in a standard fashion
Mobilization of the gastric fundus
Division of short gastric arteries
Dissection of the esophageal hiatus
Careful dissection around the distal esophagus and gastroesophageal junction
Creation of a 360-degree wrap using the gastric fundus
Secure the wrap with sutures
Assess for adequate fit and hemostasis
Placement of nasogastric tube for decompression.
Open Nissen:
Midline or subcostal incision
Similar dissection and mobilization of the gastric fundus and esophagus as in the laparoscopic approach
Creation and securing of the fundoplication wrap
Closure of abdominal layers.
Key Technical Aspects:
Adequate mobilization of the fundus to avoid tension on the wrap
Precise dissection of the esophagus to avoid injury to the vagus nerves
Ensuring the wrap is not too tight (avoiding dysphagia) or too loose (risk of recurrence)
The wrap should cover at least 2-3 cm of the distal esophagus
Proper anchoring of the wrap to prevent slippage.
Postoperative Care
Immediate Postoperative:
Pain management
Nasogastric tube decompression for 24-48 hours or until bowel sounds return
Gradual advancement of diet starting with clear liquids, progressing to pureed foods, then soft foods
Monitoring for bleeding, infection, and signs of gastric outlet obstruction
Early ambulation.
Dietary Progression:
Strict adherence to a progressive diet is crucial
Patients are typically on clear liquids for the first few days, then advance to full liquids, pureed diet for 1-2 weeks, followed by soft diet
Avoidance of carbonated beverages, caffeine, spicy foods, and gas-producing foods
Small, frequent meals are recommended
Long-term, patients may need to chew food thoroughly.
Medications And Monitoring:
Continued PPI therapy is often recommended, especially in the early postoperative period, though many patients can eventually wean off
Antibiotics may be used prophylactically
Regular follow-up appointments to assess symptom resolution, dietary tolerance, and identify any early complications
Monitoring for wound healing and signs of infection.
Complications
Early Complications:
Bleeding from short gastric arteries or esophageal dissection
Injury to esophagus, stomach, spleen, or diaphragm
Pneumothorax
Gastric outlet obstruction
Nausea and vomiting
Dysphagia (difficulty swallowing) due to tight wrap or edema
Gas-bloat syndrome (abdominal distension and pain due to inability to belch)
Wound infection.
Late Complications:
Recurrent GERD due to wrap slippage or disruption
Persistent or new-onset dysphagia requiring bougienage or revision surgery
Marginal ulcers at the gastroesophageal junction
Diaphragmatic hernia
Gastric fistula
Weight loss or malnutrition from severe dysphagia.
Prevention And Management:
Meticulous surgical technique is key to preventing early complications
Careful patient selection and preoperative optimization reduce surgical risk
Postoperative dietary adherence is critical for preventing dysphagia and gas-bloat syndrome
Management of dysphagia may involve dietary adjustments, PPIs, bougienage, or revision surgery
Recurrent GERD may require further medical or surgical intervention.
Prognosis
Outcomes:
Nissen fundoplication is highly effective in controlling GERD symptoms in appropriately selected patients, with success rates generally ranging from 80-90% in experienced hands
Long-term symptom relief is common, reducing the need for lifelong medication
Quality of life is significantly improved.
Factors Affecting Prognosis:
Patient selection is paramount
patients with severe GERD refractory to medical management tend to have better outcomes than those with mild symptoms
Technical proficiency of the surgeon and adherence to postoperative dietary recommendations significantly influence long-term success
Presence of comorbidities can impact recovery and overall outcomes.
Follow Up:
Routine follow-up is recommended at 1 week, 1 month, 3 months, and 6 months postoperatively, and then annually as needed
Long-term follow-up focuses on symptom recurrence, dietary tolerance, and assessment for any late complications
Patients with Barrett's esophagus require continued endoscopic surveillance.
Key Points
Exam Focus:
Indications for Nissen fundoplication in refractory GERD
Contraindications
Key steps of both laparoscopic and open procedures
Management of early and late complications, especially dysphagia and gas-bloat
Role of PPIs postoperatively
Differentiating between 270-degree (partial) and 360-degree (total) fundoplication and their implications.
Clinical Pearls:
Always confirm adequate esophageal length for the wrap to avoid tension
The wrap should allow passage of a bougie (e.g., 32-36 Fr) to prevent tight constriction
Careful identification and preservation of the vagus nerves are essential
Postoperative dietary counseling must be thorough and emphasized
Consider revision surgery for persistent symptoms after excluding other causes.
Common Mistakes:
Performing surgery in patients with purely functional heartburn or inadequate diagnosis of GERD
Inadequate mobilization of the fundus leading to a tight wrap and dysphagia
Overtightening the wrap, causing significant dysphagia and inability to belch
Insufficient wrap length or loose wrap leading to recurrence
Ignoring or damaging vagus nerves during hiatal dissection.