The traditional surgical treatment for patients with severe reflux symptoms.
Page reviewed by: Mr Nicholas Boyle BM MS FRCS 03/07/20
Fundoplication involves wrapping the top of the stomach (called the fundus) around the bottom of the oesophagus (also known as the gullet or food pipe) and then stitching it to itself. The operation aims to create a new high pressure zone to strengthen the lower oesophageal valve (LOS), preventing stomach contents from refluxing into the oesophagus. There are several variations of fundoplication during which different amounts of the stomach is wrapped either in front or behind the oesopagus. The most common procedure is called the Nissen and is a 360 degree fundoplication. Others are “partial” fundoplications of 180 or 270 degrees and include Dor, Watson, Hill and Toupet. All named after the surgeons who first described them. While these variations all have theoretical advantages, there is no strong evidence that one kind of procedure is better than another. The success of the operation is mainly dependent on the patient selection or the skill of the surgeon.
Fundoplication is a laparoscopic or keyhole operation. The surgeon makes four or five small incisions in the abdomen and then passes instruments through these incisions. The instruments include a laparoscope which allows the surgeon to see what they're doing on a high definition screen. If a Hiatus Hernia (when part of the stomach is protruding through the diaphragm) is present this is repaired at the same time. This operation takes around 60 - 90 minutes.
As with any surgical procedure there are risks (including blood loss, damage to internal organs, etc.) during the operation but the chances of these occurring are small. The bigger issue is that fundoplication operations are known to cause side effects in many patients. The fundoplication is not a valve and so can’t open and close. Following surgery, problems can include difficulty swallowing and an inability to belch or vomit. Over half of patients may experience significant bloating and associated wind symptoms. These side effects may resolve without treatment although they can persist permanently.
In well selected patients, fundoplication can be a good choice. Clinical data shows that the majority of patients enjoy better quality of life following fundoplication compared to patients taking medication. Surgery is particularly helpful in controlling heartburn and regurgitation symptoms.
However, there are several issues with fundoplications, one of the most common is that over time they tend to fail. Even though the stomach is stitched to the oesophagus, whenever the patient eats a meal, both the oesophagus and stomach move around. Therefore, over time the stitches tend to loosen and occassionally the wrap will slip. This normally causes a return of the reflux symptoms. Hiatus hernias also tend to recur as they are often caused by a degenerative condition. After 5 years, up to half of fundoplication patients will be back on anti-acid medication and some will choose to have another operation to try and eliminate the sypmtoms.
Studies have shown that, over time, the effect of the operation diminishes and that many patients’ symptoms return. Five years after the operation 25-50% of patients will have experienced a return of some of their symptoms and many of these will be taking medication once more. However, overall quality of life still appears to be better in patients who had surgery than in those who have not. Clinical data shows that up to 10% of patients may need a further operation within 5 years either because of symptom recurrence or problems with the fundoplication. Re-do surgery is inevitably likely to be more complicated than first time operations.
Some patients can return home on the day of surgery and virtually everyone else is able to do so the following day. Most people find they are able to resume the majority of their normal activities 2-3 weeks after surgery.