What is the Nissin fundoplication procedure and when is it recommended for patients with gastroesophageal reflux disease (GERD)?

Nissen Fundoplication: Procedure and Indications

What is Nissen Fundoplication?

Nissen fundoplication is a 360-degree wrap of the gastric fundus around the distal esophagus, performed laparoscopically, that serves as the gold standard surgical treatment for gastroesophageal reflux disease (GERD) by creating a mechanical barrier to prevent acid reflux. 1

The procedure involves:

• Mobilization of the gastric fundus by dividing the short gastric vessels to create adequate tissue for the wrap 1
• Complete dissection of the phrenoesophageal ligament to isolate the esophagogastric junction 1
• Closure of the diaphragmatic hiatus using non-absorbable sutures to repair any associated hiatal hernia 1
• Creation of a tension-free 360-degree wrap around the lower esophagus, typically 2-3 cm in length 1, 2

When is Nissen Fundoplication Recommended?

Primary Indications

Surgery is indicated when there is pathologic GERD with severe esophagitis (LA Grade C or higher) that is uncontrollable with medical therapy. 1

Specific clinical scenarios include:

• Failure of medical therapy with proton pump inhibitors (PPIs) to control symptoms or heal esophagitis 2, 3
• Severe complications of GERD including ulceration, stricture formation, or Barrett's esophagus 2, 4
• GERD-related respiratory symptoms such as chronic cough, asthma, or aspiration that are thought secondary to reflux 5, 6
• Patient inability or unwillingness to continue lifelong medical therapy despite documented GERD 2

Critical Preoperative Requirements

Before proceeding with fundoplication, mandatory diagnostic confirmation must include mechanically defective lower esophageal sphincter on manometry AND increased esophageal acid exposure on 24-hour pH monitoring. 4

The complete preoperative workup must include:

• 24-hour multichannel intraluminal impedance-pH monitoring as the gold standard for confirming pathologic GERD 7, 6
• Upper endoscopy with biopsies to document LA classification grade of erosive esophagitis and rule out complications 1
• High-resolution esophageal manometry to assess peristaltic function and exclude achalasia or severe motility disorders 1
• Barium swallow to identify hiatal hernia, strictures, or short esophagus before surgery 7, 1

Patient Selection Pitfalls

If acid suppression with PPIs is ineffective preoperatively, the accuracy of the GERD diagnosis must be reassessed, as fundoplication may not produce optimal clinical results. 6

Conditions that must be carefully ruled out before surgery include:

• Cyclic vomiting syndrome, rumination, or gastroparesis as these will not respond to fundoplication 6
• Eosinophilic esophagitis which mimics GERD but requires different treatment 6
• Achalasia or severe esophageal dysmotility which would be worsened by fundoplication 1

High-Risk Populations Requiring Special Consideration

Children with neurologic impairment, esophageal atresia-tracheoesophageal fistula repair history, diffuse motility disorders, chronic pulmonary disease, and young infants have significantly higher failure rates. 6

For patients with esophageal atresia-tracheoesophageal fistula:

• Laparoscopic fundoplication is the recommended surgical approach when anti-reflux surgery is needed 7
• The choice between total (Nissen) or partial fundoplication should be left to surgeon expertise, though partial fundoplication should be strongly considered in patients with impaired esophageal peristalsis 7, 6
• The possibility of a "short" esophagus must be considered, potentially requiring lengthening procedures (Collis gastroplasty) especially in revision cases 7

Surgical Approach and Technique

The laparoscopic approach is preferred over open surgery with an excellent safety profile, reporting overall in-hospital mortality of 0.14%. 1, 6

Key technical principles:

• The wrap must be tension-free to prevent postoperative complications 1
• Hiatal closure is essential to prevent wrap herniation and recurrent reflux 1
• Vagus nerve preservation during esophageal dissection is critical 1

Expected Outcomes and Complications

Efficacy

Laparoscopic Nissen fundoplication provides excellent control of reflux symptoms with 97% patient satisfaction and significant improvement in both esophageal and extraesophageal symptoms. 4, 5

Objective improvements include:

• Percentage time with esophageal pH <4 decreases from 10.18% to 0.85% postoperatively 3
• Lower esophageal sphincter pressure increases from 7.82 mm Hg to 22.00 mm Hg 3
• Extraesophageal symptoms (asthma, cough, chest pain) are greatly improved or resolved in 67-82% of patients 5

Common Complications

Postoperative dysphagia affects 5-43% of patients and represents the most frequent complication, occurring more commonly after total fundoplication compared to partial wraps. 6

Other complications include:

• Gas bloat syndrome where patients cannot belch or vomit effectively, with associated flatulence and early satiety 6
• Intraoperative complications including gastric/esophageal perforation (1.5%), pneumothorax (1%), and bleeding (1%) 4
• Recurrent reflux requiring reoperation in approximately 1-2% of cases 4

Hospital Stay and Recovery

Median hospital stay is 2-3 days with mean return to work of 12.6 days. 3, 4

Postoperative Management

For persistent dysphagia post-fundoplication, upper GI endoscopy, manometry, pH studies, and barium swallow should be performed first to assess wrap integrity before considering revision. 6

Endoscopic surveillance is recommended to monitor healing and detect potential complications, particularly in patients with Barrett's esophagus or complex anatomy. 6