Antireflux Surgery and Fundoplication
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Direct answer
Heartburn that dominates a patient's life despite proton pump inhibitors, with volume regurgitation and a hiatus hernia, is the classic candidate for antireflux surgery — but the operation is only offered after objective proof of reflux: upper GI endoscopy (oesophagitis, Barrett's), 24-hour ambulatory pH monitoring (percent time pH below 4 exceeding about 4.2 per cent, or DeMeester score above 14.7) and, critically, manometry to exclude achalasia and assess peristalsis. The standard operation is a laparoscopic Nissen fundoplication — a floppy 360-degree wrap of the gastric fundus around the distal oesophagus over a 56–60 Fr bougie, with crural repair — converted to a partial wrap (posterior 270-degree Toupet, or anterior Dor) when peristalsis is weak or absent, after myotomy, or in severe oesophageal dysmotility, to avoid the gas-bloat and dysphagia a total wrap can cause.
What you must remember
- Indications: dependence on or failure of proton pump inhibitors with objectively proven reflux; regurgitation-dominant (volume) reflux, which drugs suppress poorly; large hiatus hernia with mechanical symptoms; complications — Barrett's oesophagus, peptic stricture, chronic respiratory symptoms or aspiration attributed to reflux.
- Mandatory preoperative trio: endoscopy, ambulatory pH study (off proton pump inhibitors) and high-resolution manometry; a barium swallow adds anatomical detail — operating without this workup is how achalasia gets wrapped, a disaster.
- Nissen: 360-degree total fundoplication, made "floppy" over a large bougie with division of short gastric vessels in many centres; Toupet: 270-degree posterior partial; Dor: 180–200-degree anterior partial (commonly paired with Heller myotomy).
- Crural repair (posterior hiatal closure, ± reinforcement) and restoration of 2–3 cm of intra-abdominal oesophagus are as important as the wrap — the operation rebuilds the anti-reflux barrier, not just a cuff.
- Choose partial wrap when: weak or absent peristalsis (ineffective motility), post-myotomy, oesophageal dilation, or severe gas-bloat tendency; total wraps in aperistaltic oesophagus risk persistent dysphagia.
- Complications: dysphagia (transient in most, persistent in a few percent), gas-bloat syndrome (inability to belch or vomit, bloating, flatulence), paraesophageal herniation of the wrap, slipped wrap onto the stomach, dumping symptoms, and wrap failure with recurrent reflux over the long term.
- Red flags that mimic reflux and must be excluded: achalasia (manometry), eosinophilic oesophagitis (biopsy), and malignancy (endoscopy in any alarm feature — dysphagia, weight loss, anaemia, age over 55 with new symptoms).
A typical case worked through
A 38-year-old woman has ten years of retrosternal burning and, more troublingly, wakes at night coughing with acid in her mouth; she doubles her omeprazole dose without full relief. Walk the pathway: endoscopy first — grade B oesophagitis with a 4 cm hiatus hernia, biopsies negative for Barrett's and eosinophilia. Because surgery is on the table, objective reflux metrics follow: 24-hour pH-Bravo study off proton pump inhibitors shows per cent time pH below 4 at 9 per cent with a DeMeester score of 34; high-resolution manometry shows a hypotensive lower oesophageal sphincter with normal peristaltic reserve. That combination — proven abnormal acid exposure, mechanical/regurgitant symptoms, a hernia, intact peristalsis — is the ideal fundoplication candidate. At laparoscopy: hernia sac reduction, crural closure, and a floppy Nissen over a bougie; she stays on soft diet for two weeks. In clinic at six months, she belches normally, sleeps flat and has stopped all acid suppression. Contrast the branch points: had manometry shown absent peristalsis, a Toupet wrap; had pH testing been normal despite symptoms, surgery would be a mistake — that patient has functional heartburn and belongs on medical and behavioural therapy. And had she returned with early solid-food dysphagia, the answer is endoscopic dilation first, reserving reoperation (wrap revision or conversion to partial) for structural failure confirmed on barium swallow and endoscopy.
Where students slip
The exam's favourite trap is the sequence — students jump to "Nissen" without demanding pH and manometry proof, then cannot answer why manometry is essential (to exclude achalasia and to choose total versus partial wrap; wrapping an aperistaltic or spastic oesophagus creates dysphagia). The second slip is misremembering wrap degrees: Nissen 360, Toupet 270 posterior, Dor 180–200 anterior — and which is paired with Heller myotomy (Dor, or Toupet). Third, gas-bloat syndrome is often left out of the complications list even though it is the quality-of-life complication patients ask about at consent.
Frequently asked questions
Which investigations are mandatory before fundoplication?
Upper GI endoscopy, 24-hour ambulatory pH monitoring (percent time pH below 4 over about 4.2 or DeMeester score over 14.7) and oesophageal manometry — all three, off proton pump inhibitors for the pH study.
What are the degrees of wrap in Nissen, Toupet and Dor fundoplication?
Nissen is a complete 360-degree wrap, Toupet a 270-degree posterior partial wrap, and Dor a 180–200-degree anterior partial wrap.
When is a partial fundoplication preferred over Nissen?
With weak or absent peristalsis, significant oesophageal dysmotility, mega-oesophagus, or after Heller myotomy — total wraps in these settings cause dysphagia and gas-bloat.
What is gas-bloat syndrome?
Post-fundoplication inability to belch or vomit with postprandial bloating, flatulence and early satiety caused by an over-tight or total wrap around a gas-producing stomach.
Does surgery outperform proton pump inhibitors long term?
Randomised trials show broadly equivalent symptom control; surgery abolishes daily medication but adds operative and wrap-failure risks, so selection and counselling decide.