From the Guidelines
Nissen fundoplication is a highly effective and safe procedure for patients with severe gastroesophageal reflux disease (GERD) who have failed medical management or have complications such as large hiatal hernias or Barrett's esophagus, with a mortality rate below 1% and major complication rates of 5-10%. The indications for Nissen fundoplication include:
- Severe GERD that has not responded to medical management with proton pump inhibitors (PPIs) like omeprazole or esomeprazole
- Large hiatal hernias
- Barrett's esophagus
- Complications such as esophageal strictures, chronic cough, or aspiration pneumonia due to reflux
- Patients who cannot tolerate long-term PPI therapy
The procedure involves wrapping the upper portion of the stomach (fundus) around the lower esophagus to strengthen the lower esophageal sphincter and prevent acid reflux, as supported by the AGA clinical practice update on the personalized approach to the evaluation and management of GERD, which states that laparoscopic fundoplication is an effective surgical option for patients with proven GERD 1. According to a Cochrane systemic review, laparoscopic fundoplication surgery has been shown to have statistically significant improvements in health-related QOL at 3 months and 1 year compared with medical therapy 1.
Common complications of the procedure include:
- Dysphagia (difficulty swallowing)
- Gas-bloat syndrome
- Inability to belch or vomit However, most patients can expect significant symptom improvement, with 80-90% reporting satisfaction after five years. The laparoscopic approach is preferred when possible, as it results in shorter hospital stays (1-2 days), less pain, and faster recovery compared to open surgery. Patients should understand that while the procedure effectively controls reflux symptoms, it is not without potential side effects and lifestyle modifications may still be necessary. Recovery typically takes 2-6 weeks, with patients starting on a liquid diet and gradually advancing to solids.
From the Research
Indications for Nissen Fundoplication
- Severe or complicated gastroesophageal reflux disease (GERD) that is not responsive to medical treatment 2, 3, 4
- Documented abnormal esophageal acid exposure by 24-hour pH probe monitoring 2
- Mechanically defective lower esophageal sphincter as confirmed by esophageal manometry 2
- Absence of severe esophageal and/or gastric motility disorders 2
- Failure of proton pump inhibitor (PPI) therapy 3, 4, 5
Safety of the Procedure
- Laparoscopic Nissen fundoplication can be performed with excellent symptomatic and physiologic results and a morbidity rate comparable to conventional open antireflux procedures 2
- Intraoperative morbidity rate of 9% and major postoperative complications in 4% of patients 2
- Common postoperative complications include dysphagia, deep venous thrombosis, delayed gastric leak, and trocar site hernia 2, 3
- Average hospital stay of 3.0 days and average time to return to normal activity of 7.0 days 2
- Patient satisfaction is high, but PPI non-responders may have a lower satisfaction rate compared to PPI responders 3