Laparoscopic Nissen fundoplication combined with posterior gastropexy in the surgical treatment of gastroesophageal reflux disease (GERD)

Abstract

We read with interest the work by Tsimogiannis et al. [1], whose prospective randomized trial supported the use of a posterior gastropexy as a component to laparoscopic Nissen fundoplication. The level of evidence they reported is crucial to standardizing the technique of laparoscopic antireflux surgery. To date, evidence has largely been either observational or retrospective in nature despite the fact that antireflux surgery has been described for half a century.The inclusion of a gastropexy to prevent herniation of the fundoplication into the chest can be attributed to Rudolph Nissen [2] in 1961. Shortly thereafter, in the late 1960s, Lucius Hill [3] pioneered the repair that bears his name by demonstrating a successful posterior gastropexy that entailed anchoring the gastroesophageal junction to the median arcuate ligament. By 1977, after using this approach for 559 patients undergoing surgery for hiatal hernia, Dr. Hill [4]reported only 5 (0.89%) recurrences with 95% follow-up assessment.We applaud the authors for finally providing level 1 evidence that a posterior gastropexy has a positive impact on the results of the operation without worsening dysphagia. We in fact use a posterior gastropexy routinely during our laparoscopic Nissen fundoplications, even after lung transplantation [5]. Furthermore, in addition to the gastropexy described by Tsimogiannis et al.[1], we routinely place two stitches, one on each side of the fundoplication, to pexy the fundoplication and the esophagus to the diaphragm. These ''apical'' stitches incorporate the top of the fundoplication, the esophagus, and the uppermost portion of the crus, and at the same time pexy the fundoplication so as to avoid telescoping of the esophagus through the repair.

Efficacy of transoral incisionless fundoplication for refractory gastroesophageal reflux disease: a systematic review and meta-analysis

“…The minimally invasive approach and significantly improved outcomes following TIF procedures suggest an increasing role for TIF. At present, laparoscopic Nissen fundoplication is still the gold standard for the surgical treatment of GERD, though TIF appears to be an emerging option for patients with refractory GERD [11,12]. TIF may be a valuable option in high-risk surgical patients or in patients who refuse surgery.…”

Additional fundophrenicopexia, after Nissen fundoplication, reduces postoperative dysphagia and re-operation rate in the long-term follow up

“…[ 11 – 13 ] Still no consensus exists whether the SGV should be ligated or not or whether the fundoplication wrap or/and remaining stomach should be fixated to the crus or not. [ 21 , 26 – 28 , 39 , 40 ] Thus, it ultimately depends on the surgeon how the NF is performed precisely. Creating a 360° tension-free wrap, no longer then 1,5 cm length, with two non-absorbable sutures, including the esophagus in the first one remained the basis of our NF from beginning to date.…”

“…[ [26][27][28] Encouraged by these results we integrated suturing the fundoplication wrap with the right crus (fundophrenicopexia) with two non-resorbable sutures.…”

“…Without worsening the dysphagia rates, posterior gastropexy has shown to have a positive impact on the postoperative outcome of NF. [ 26 – 28 ] Encouraged by these results we integrated suturing the fundoplication wrap with the right crus (fundophrenicopexia) with two non-resorbable sutures.…”