Nissen fundoplication

Overview
Nissen fundoplication is a surgical procedure to treat gastroesophageal reflux disease (GERD) and hiatus hernia. In GERD it is usually performed when medical therapy has failed, but with paraesophageal hiatus hernia, it is the first-line procedure. Partial fundoplications known as a Dor fundoplication or Toupet fundoplication may accompany surgery for achalasia.

The procedure
In a fundoplication, the gastric fundus (upper part) of the stomach is wrapped, or plicated, around the inferior part of the esophagus, restoring the function of the lower esophageal sphincter. This prevents the reflux of gastric acid (in GERD) and/or the sliding of the fundus through the enlarged esophageal hiatus in the diaphragm. In a Nissen fundoplication, also called a complete fundoplication, the fundus is wrapped all the way around the esophagus.

Surgery for achalasia is generally accompanied by either a Dor or Toupet partial fundoplication. In a Dor (anterior) fundoplication, the fundus is laid over the top of the esophagus. In a Toupet (posterior) fundoplication, the fundus is wrapped around the back of the esophagus.

The procedure is often done laparoscopically. When used as a method to alleviate gastroesophageal reflux symptoms in patients with delayed gastric empyting, this procedure is frequently done in conjunction with modification of the pylorus via pyloromyotomy or pyloroplasty.

Nissen fundoplication is generally considered to be safe and effective, with a mortality rate of less than 1%. Studies have shown that after 10 years, 89.5% of patients are still symptom-free.

Complications
Complications include "gas bloat syndrome", dysphagia (trouble swallowing), dumping syndrome, excessive scarring, and rarely, achalasia. The procedure can also become undone over time in about 5-10% of cases, leading to recurrence of the symptoms. If the symptoms warrant repeated surgery, the surgeon may use Marlex or another form of artificial mesh to strengthen the connection.

In "gas bloat syndrome", patients report being unable to belch, leading to an accumulation of gas in the stomach or small intestine. This is said to occur in 2-5% of patients, depending on surgical technique, and is commonly believed to be related to the tightness of the "wrap". Most often, gas bloat syndrome is self-limiting within 2 to 4 weeks, but in some it may persist. The offending gas may come from dietary sources (especially carbonated beverages). Another suspected cause is subconscious swallowing of air (aerophagia). If gas bloat syndrome occurs post operatively and does not resolve with time, dietary restrictions, or counselling regarding aerophagia, it may be beneficial to consider treating the condition with an endoscopic balloon dilitation.

History
Dr. Rudolph Nissen first performed the procedure in 1955, and published the results of two cases in a 1956 Swiss Medical Weekly. In 1961 he published a more detailed overview of the procedure. Nissen originally called the surgery gastroplication, but the procedure has borne his name since it gained popularity in the 1970's.