Update: Total versus Partial Laparoscopic Fundoplication

Abstract

Since the introduction of Nissen fundoplicaton in 1956, there has been concern about the incidence of troublesome mechanical complications, which has necessitated several modifications reducing the overall incidence to around 15%. Increasing knowledge of the pathophysiology of Nissen fundoplication has revealed that these complications are associated with a supracompetent high pressure zone (HPZ) which relaxes incompletely on swallowing and is associated with abolition of gas reflux and physiological acid reflux. Partial fundoplication procedures, which augment various constituents of the valvuloplasty component of competence and utilise a lesser degree of fundoplication, are associated with a very low incidence of mechanical complications, but debate has ensued that reflux control may be suboptimal and less durable than after Nissen fundoplication. However, several good, objective comparative studies and three prospective randomised trials have confirmed that a well conducted partial fundoplication procedure is at least as effective and durable in reflux control as Nissen fundoplication, whilst being associated with a lower incidence of mechanical complications. The debate has intensified since the advent of laparoscopic fundoplication, as several reports have highlighted the increased incidence of mechanical complications following Nissen fundoplication when performed laparoscopically compared with the open approach, with a higher incidence of impaired HPZ relaxation, believed to be associated with altered geometry and other factors inherent in laparoscopic fundoplication. This has resulted in re-operation rates for complications of laparoscopic Nissen fundoplication of 1–7%, and in the laparoscopic era, mechanical complications have overtaken recurrent reflux as the principal reason for revisional fundoplication. Several non-randomised series have shown that laparoscopic partial fundoplication procedures are associated with a similarly low incidence of mechanical complications and a negligible re-operation rate as at open operation, with retention of physiologial HPZ relaxation. These factors have resulted in increasing deployment of partial fundoplication procedures, and increasing support for the ‘tailored’ approach to anti-reflux surgery. Several prospective randomised studies between laparoscopic partial and total fundoplication procedures are currently in progress, and early results favour partial fundoplication because of the considerably lower incidence of mechanical complications. The continuance of these studies, as well as those underway which compare different partial fundoplication procedures and include economic and quality-of-life assessment, should enable the rational choice of the most appropriate laparoscopic anti-reflux procedure to be placed on a firm scientific footing.

Manometric characteristics of the gastroesophageal junction after anterior versus posterior partial fundoplication

“…Partial fundoplication has been developed and launched to circumvent at least some of these problems 25,26 . However, over the years most surgeons have advocated a posterior partial fundoplication although the focus of research has recently changed toward various anterior fundoplication procedures 27 . Concern has been raised regarding the efficacy of these procedures to control gastroesophageal reflux 28 .…”

Effect of different types of fundoplication on the gastric emptying of liquids and gastric compliance in rats

“…There are evidences that partial techniques can achieve the same reflux control as the Nissen operation, with a lower incidence of postfundoplication symptoms such as gagging and bloating [2,16]. It has been postulated that the high IGP associated with the low GV and GC after Nissen procedure could be responsible for a higher incidence of those adverse events when compared with partial wraps [9][10][11].…”

Repeat Antireflux Surgery: Effectiveness of a Toupet Partial Posterior Fundoplication

“…The attractiveness of carrying out a partial posterior fundoplication for repeat operations is based on the fact that this procedure augments various constituents of the valvuloplastic components of the competence of the gastro-oesophageal junction and by using a lesser degree of fundoplication fewer mechanical complications follow (4,14,23). The attractiveness of carrying out a partial posterior fundoplication for repeat operations is based on the fact that this procedure augments various constituents of the valvuloplastic components of the competence of the gastro-oesophageal junction and by using a lesser degree of fundoplication fewer mechanical complications follow (4,14,23).…”