What are the indications for fundoplication in patients with gastroesophageal reflux disease (GERD)?

Indications for Fundoplication in GERD

Fundoplication is indicated for patients with objectively documented gastroesophageal reflux who have failed medical therapy, specifically those with refractory symptoms despite PPI treatment or those requiring continuous high-dose PPI therapy with unacceptable side effects. 1

Primary Indications

Refractory GERD Despite Medical Therapy

• Patients with persistent typical GERD symptoms (heartburn, regurgitation) despite standard-dose PPI therapy represent the most common indication, accounting for approximately 64% of surgical candidates 2
• Objective documentation of pathologic reflux through 24-hour pH monitoring or impedance-pH testing is mandatory before proceeding to surgery—98% of appropriate surgical candidates demonstrate abnormal pH studies 2, 3
• Surgery should only be offered when reflux has been objectively confirmed, as extra-esophageal symptoms often have non-GERD etiologies 1

Severe Erosive Esophagitis

• LA Grade C or higher erosive esophagitis that is uncontrollable with medical therapy constitutes a strong indication for surgical intervention 4, 5
• Approximately 51% of surgical candidates have erosive esophagitis, stricture, or Barrett's metaplasia at presentation 2
• The presence of complications such as strictures or Barrett's esophagus strengthens the indication for definitive surgical management 4, 5

PPI-Dependent Patients with Quality of Life Issues

• Patients requiring daily omeprazole or high-dose H2 antagonists to control symptoms who wish to discontinue lifelong medication represent appropriate candidates 2
• The LOTUS trial demonstrated higher remission rates with surgery (85%) versus medical therapy (92%) at 5 years, though this difference became non-significant after accounting for dropouts 1
• Surgery provides statistically significant improvements in health-related quality of life at 3 months and 1 year compared to continued medical therapy 1

Essential Preoperative Evaluation

Mandatory Testing Before Surgery

• Upper endoscopy to document LA classification grade, identify hiatal hernia size, and rule out Barrett's esophagus or malignancy 4, 5
• 24-hour pH monitoring or impedance-pH monitoring off PPI therapy to confirm pathologic acid exposure and establish symptom-reflux correlation 3
• High-resolution esophageal manometry to assess peristaltic function, exclude achalasia, and guide choice between total versus partial fundoplication 4, 5
• Barium swallow to identify hiatal hernia, assess for strictures, and detect short esophagus 4, 5

Critical Pitfall to Avoid

• Never proceed to fundoplication without objective documentation of pathologic reflux, as functional heartburn patients (normal acid exposure with negative symptom association) respond poorly to surgery and should not undergo fundoplication 1
• Patients with extra-esophageal symptoms (hoarseness, chronic cough, asthma) who fail PPI therapy must be investigated for non-GERD causes before considering surgery, as these symptoms are least likely to be GERD-related 1

Specific Clinical Scenarios

Patients with Hiatal Hernia

• Small sliding hiatal hernias (≤2-3 cm) associated with severe esophagitis require surgical repair with concurrent fundoplication 4
• Hiatal closure with non-absorbable sutures is essential during fundoplication to prevent wrap herniation and recurrent reflux 4, 5
• Approximately 72% of fundoplication candidates have small hiatal hernias at presentation 6

Patients with Impaired Esophageal Motility

• Patients with severely impaired esophageal peristalsis (approximately 17% of candidates) should undergo partial fundoplication (Toupet 270°) rather than complete Nissen fundoplication to avoid postoperative dysphagia 2, 7
• Partial fundoplication corrects abnormal reflux while avoiding dysphagia and gas bloat syndrome in patients with weak peristalsis 7
• Patients with aperistalsis (approximately 2% of candidates) require careful consideration, as fundoplication outcomes may be suboptimal 2

Surgical Approach and Expected Outcomes

Laparoscopic Technique

• Laparoscopic fundoplication is the standard approach with an excellent safety profile (in-hospital mortality 0.14%, conversion rate 0.5%) 4, 5, 8
• Nissen fundoplication (360° wrap) remains the gold standard for durable symptom relief, with 93% of patients heartburn-free at 1 year and 91% maintaining normal pH studies long-term 5, 2
• Toupet fundoplication (270° posterior wrap) should be strongly considered in patients with impaired peristalsis to reduce dysphagia risk 5, 7

Common Complications to Counsel Patients About

• Postoperative dysphagia occurs in 5-43% of patients, more commonly after total fundoplication than partial wraps 5
• Gas bloat syndrome (inability to belch or vomit effectively, with flatulence and early satiety) represents a common complication 1, 5
• Approximately 4% of patients require daily PPI therapy postoperatively, and 4.3% require operative revision 8

Long-Term Success

• At mean follow-up of 5.6 years, careful patient selection and proper technique provide satisfying results in the majority of patients with severe GERD 8
• Atypical reflux symptoms (asthma, hoarseness, chest pain, cough) are eliminated or improved in 87% of patients 2
• Overall patient satisfaction reaches 97% when appropriate candidates are selected 2