Definition & Overview
A Nissen fundoplasty, also known as fundoplication, is a surgical procedure used to treat gastroesophageal reflux disease (GERD) and associated hiatal hernia. In most cases, it is not considered the first line of treatment and is secondary to medical therapy. It is often performed when the patient is unable to take medications for an extended period or when medications have failed to improve the condition. It is, however, the primary treatment method for paraesophageal hiatus hernia.
Due to the latest surgical technologies available, a Nissen fundoplasty can now be performed laparoscopically, a method that significantly reduces blood loss and surgical risks.
The Nissen fundoplasty was developed by Dr. Rudolf Nissen in the 1950s. The original procedure was meant to treat severe reflux oesophagitis wherein the fundus is wrapped around the oesophagus. This standard fundoplication has already been modified several times.
Who Should Undergo and Expected Results
A Nissen fundoplasty is performed on patients who suffer from gastroesophageal reflux disease (GERD). It can also resolve the symptoms of a hiatal hernia. The symptoms of these conditions include:
- Acid reflux
GERD can be managed with medical therapy and other less invasive treatment. However, surgery is recommended in cases of the following:
- Serious GERD complications such as Barrett’s oesophagus and peptic stricture
- Failed medical therapy
- Juvenile oesophagitis
- Mixed and paraesophageal hernia
- Intolerance to GERD medications
- Inability to take medications for an extended period
- Advanced cardiopulmonary disease
- Portal hypertension
It is best for patients to discuss their treatment options with their primary care provider.
One of the biggest concerns that patients and doctors have about surgical treatments for GERD is the recovery process. Following an open surgery, patients can expect to stay in the hospital for several days. The recovery process may take an average of 4 to 6 weeks before the patient can return to his normal routine.
On the other hand, if the patient undergoes a laparoscopic procedure, the hospital stay is just 2-3 days. The patient will also experience less pain and discomfort after the procedure, and can go back to work and other normal activities in just 2 to 3 weeks. Aside from faster recovery, the laparoscopic procedure has several advantages over open surgery, such as reduced complications and morbidity. In the majority of patients who undergo laparoscopic Nissen fundoplasty, the procedure effectively improves symptoms and heals the damage to the oesophagus.
In some patients, however, symptoms may come back, or new symptoms may develop. New symptoms may include:
- Difficulty swallowing
- Difficulty belching
- Increased gas or flatulence
During the recovery process, patients are advised to go on a soft diet to give the oesophagus enough time to heal.
How is the Procedure Performed?
A Nissen fundoplasty can be performed either through open surgery or minimally invasive laparoscopic procedure. The method may vary, but the goals of the procedure are the same. Both are performed under general anaesthesia either through the chest or the abdomen. The abdominal procedure is more commonly used, while the chest approach is often reserved in cases where the patient either has a short oesophagus or is overweight or obese.
The surgery works by wrapping the upper curve of the stomach, which is called the fundus, around the oesophagus and sewing it into place. This makes the lower portion of the oesophagus pass through a tunnel of stomach muscle to strengthen the valve between the oesophagus and the lower oesophageal sphincter.
After the procedure, the valve between the oesophagus and the stomach can stop the acid from going back up into the oesophagus, thus resolving symptoms of GERD.
Possible Risks and Complications
A Nissen fundoplasty is associated with certain risks, including:
- Difficulty swallowing when the stomach is wrapped around the oesophagus either too tightly or too high
- Excess gas
- Pain at the surgical site
There is a risk that the oesophagus may slide out of the wrapped portion of the stomach. This may cause the patient to require another procedure. Second surgeries are generally harder, riskier, and have a lower success rating.
On top of these risks, the patient also faces the common risks associated with the use of general anaesthesia, such as:
- Allergic reactions
- Nerve injuries
- Nausea and vomiting
- Muscle aches
Many of these risks can be prevented by the laparoscopic method instead of an open fundoplasty. In patients who have no problems with long-term medical therapy, less radical surgeries may be used, such as partial fundoplication or gastropexy.
For patients who are concerned about the risks and complications of the procedure, other innovative treatments for GERD may be considered. These include the magnetic sphincter augmentation, which was approved by the US FDA in 2012. The system uses multiple interlinked titanium-coated rare-earth magnets to support the lower oesophageal sphincter. This innovative treatment has shown promising results in controlling GERD-related reflux and has fewer side effects compared to both open and laparoscopic Nissen fundoplasty.
Frantzides CT, Carlson MA, Zografakis JG, Moore RE, Zeni T, Madan AK. 2006. “Post-operative gastrointestinal complaints after laparoscopic Nissen fundoplication.” Journal of the Society of Laparoendoscopic Surgeons. Jan-Mar; 10(1): 39-42. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3015672/
Singhal T, Balakrishnan S, Hussain A, Grandy-Smith S, Paix A, El-Hasani S. “Management of complications after laparoscopic Nissen’s fundoplication: a surgeon’s perspective.” Annals of Surgical Innovation and Research. 2009, 3:1. https://asir-journal.biomedcentral.com/articles/10.1186/1750-1164-3-1