From the Guidelines
Nissen fundoplication is considered a moderately complex surgical procedure. It involves wrapping the upper part of the stomach (fundus) around the lower esophagus and stitching it in place to reinforce the lower esophageal sphincter, which helps prevent stomach acid from flowing back into the esophagus. While it can be performed laparoscopically (minimally invasive) in many cases, it still requires general anesthesia, specialized surgical training, and careful technique 1. The procedure typically takes 1-3 hours to complete and involves several steps including mobilization of the esophagus, creation of a 360-degree wrap, and ensuring the wrap is neither too tight nor too loose.
Key Considerations
- Potential complications include difficulty swallowing, gas bloat syndrome, damage to nearby organs, and wrap failure 1.
- Recovery requires 2-6 weeks, with dietary modifications and activity restrictions.
- Despite its complexity, Nissen fundoplication has a good success rate (about 85-90%) for treating severe gastroesophageal reflux disease (GERD) when performed by experienced surgeons.
- The laparoscopic approach is nowadays the recommended surgical approach for anti-reflux surgery in patients with EA-TEF, and the choice between total or partial fundoplication should be left to the preferences and expertise of surgeons 1.
Surgical Approach
- The laparoscopic approach is also possible in revisional surgery, however, the possibility of a ‘short’ oesophagus must be considered in patients with EA-TEF who failed a previous operation 1.
- Other complex procedures, such as total oesophageal dissociation or oesophageal resections, are not to be recommended as first-line surgery and must be evaluated on an individual patient basis 1.
From the Research
Procedure Complexity
The complexity of the Nissen fundoplication procedure can be evaluated based on several factors, including the surgical technique, patient selection, and potential complications.
- The procedure is considered a surgical treatment of choice for gastroesophageal reflux disease (GERD) with a long-term effectiveness of above 90% 2.
- However, there can be new, persistent, and recurrent symptoms after the antireflux procedure in up to 30% of the cases, which may indicate a level of complexity in managing patient outcomes 2.
- The procedure requires adequate patient selection and the experience of the surgeon, which can impact the complexity and success of the operation 2.
Surgical Outcomes
Studies have compared the outcomes of laparoscopic Nissen fundoplication (LNF) with other treatments, such as transoral incisionless fundoplication (TIF) and proton pump inhibitors (PPIs).
- LNF has been shown to have the greatest ability to improve physiologic parameters of GERD, including increased LES pressure and decreased percent time pH <4 3.
- However, TIF produced the largest increase in health-related quality of life, although this may be due to the shorter follow-up time of patients treated with TIF vs LNF or PPIs 3.
- The overall 30-day readmission rate after LNF was 4.1%, and the overall rate of death or serious morbidity was 1.0% 4.
Post-Operative Complications
Post-operative complications and readmissions following outpatient elective Nissen fundoplication have been evaluated.
- The most common 30-day readmission diagnoses were infectious complications, dysphagia, and abdominal pain 4.
- There was no association between outpatient surgery and 30-day readmission or death or serious morbidity 4.
- LNF has been shown to provide good protection for neosquamous epithelium and could be offered as a first line of treatment after HALO RFA in selected patients 5.