Fundoplication: Old Concept for Novel Challenges?

Background

Gastroesophageal reflux disease (GERD), the most common esophageal disorder worldwide, is a progressive condition that may lead to Barrett's esophagus and adenocarcinoma. Upfront therapy with proton pump inhibitors is ineffective in up to 40% of patients. The scope of surgical therapy is to reconstruct the natural antireflux barrier provided by the diaphragmatic crura, the lower esophageal sphincter, and the gastroesophageal flap valve.

Summary

For 70 years, the 360° Nissen fundoplication has dominated the surgical scenario and is still considered the gold-standard treatment. However, over the past two decades, the Toupet and Dor partial fundoplications have emerged as alternative options to decrease the incidence of dysphagia and gas-bloat syndrome. Randomized and observational clinical studies have shown that the outcomes of partial fundoplication compare favorably with those of the Nissen and can provide satisfactory quality of life minimizing the risk of side effects. However, reflux control and anatomical integrity of partial fundoplications may fade away over time. Further research and close scrutiny of new surgical procedures and technologies is in progress to improve clinical outcomes and provide a more personalized and durable antireflux therapy.

Key Messages

Laparoscopic antireflux surgery is a safe and effective therapy for GERD. It should be performed in centers offering a comprehensive diagnostic pathway and a spectrum of techniques tailored to the individual GERD phenotype.

Fundoplication is a surgical procedure to correct both hiatus hernia and gastroesophageal reflux disease. These conditions cause symptoms (acid reflux, heartburn, and regurgitation) and complications (chronic inflammation possibly leading to cancer). The fundoplication consists of encircling the distal part of the esophagus (food pipe) with a portion of the upper portion of the stomach to allow normal passage of food while preventing the return of food to the esophagus and the mouth. Over the past 70 years, the advantages and drawbacks of this operation have been widely reported. Still, the vast majority of patients and physicians have not fully embraced this therapeutic modality due to the fear of side effects such as difficult swallowing and bloating. Therefore, a partial fundoplication approach has been proposed to avoid these side effects and to provide a surgical repair that does not alter quality of life while maintaining the patient free from reflux and not dependent on drugs (proton pump inhibitors). However, partial fundoplications may not tighten enough the sphincter (valve) located between the esophagus and the stomach, and may not be durable over time. This paper describes the history of fundoplication, the mechanisms by which gastroesophageal reflux causes symptoms and complications, the indication for surgery, the main steps of laparoscopic (keyhole) surgery, and the search for innovative and minimally invasive techniques to strengthen the sphincter in order to cure symptoms and protect the esophagus from the deleterious effects of acid reflux.

Informations de copyright

© 2024 S. Karger AG, Basel.

Déclaration de conflit d'intérêts

The authors have no conflicts of interest to declare.