Nissen fundoplication, commonly known as fundoplication surgery, has been the standard GERD, hiatal hernia and acid reflux treatment for over 50 years.

The purpose of fundoplication surgery is to prevent and reduce the occurrence of acid reflux by tightening the LES.

What is Fundoplication? Fundoplication refers to folding or wrapping, which is exactly what the surgery involves. During the surgical process, the upper curve of the stomach, known as the fundus, is gathered up and wrapped around the lower portion of the esophagus, and sutured in place. The procedure enables the lower portion of the esophagus to pass through a small tunnel that has been constructed from the stomach muscle. The surgery strengthens the LES (lower esophageal sphincter – the valve between the stomach and esophagus) which helps to stop stomach acid from gaining easy access to the esophagus. In addition, during the procedure, if present, hiatal hernias are also treated.

There are currently two types of fundoplication surgeries that are performed:

1. Laparoscopic fundoplication – This is the most common procedure for fundoplication surgery and involves the use of a laparoscope, a thin lighted tube that carries a videocamera. The laparoscope is inserted though a small incision in the abdomen. Once inserted, four additional pinpoint incisions are made in the upper abdomen. Needle-like instruments are inserted into the tiny incisions so the surgeon can perform the fundoplication surgery.

2. Open fundoplication – This is a procedure that involves making wide surgical incisions in the abdomen or chest. The surgeon will then perform the fundoplication surgery and sew up the patient’s incisions. This technique is generally used on obese patients as laparoscopic surgery is not possible or if there are complications during the laparoscopic technique.

What is the recovery time for fundoplication surgery? Recovery time depends on the surgical procedure a patient has undergone. For laparoscopic fudoplication surgery, recovery time is minimal. Patients usually remain in the hospital for 1 – 2 days, and are required to eat a soft diet for 1 – 2 weeks. However, most patients usually return to their normal activities within a week of the operation.

Open surgery fundoplication, on the other hand, has a much longer recovery time. Patients who undergo this surgery usually remain in hospital for between 4 and 6 days, and require 2 weeks of recovery time at home with specific soft diet instructions. After 3 – 4 weeks, the patient is typically able to return to work and engage in normal activities. Overall, the expected recovery time for this surgery is about 6 weeks.

Is fundoplication painful? Regardless of the type of surgery, all patients are given a general anesthetic during the operation, so there is no pain during the actual procedure. Those who undergo the laparoscopic surgery usually have minimal pain due to the fact that they have only received 5 tiny incisions that appear as minor blemishes. Though the area may be tender for the first day, pain medication is generally not needed 2 days after surgery.

Open fundoplication is more painful due to the fact that the patient has a large incision that needs to heal. These patients will likely take pain medication for two weeks, and will be instructed to refrain from certain activities to avoid causing pain or accidentally opening stitches.

Do acid reflux symptoms improve after surgery? For many patients, symptoms do improve, but not everyone experiences the same results. The following are a few facts to help you understand the overall success rate of fundoplication surgery:

- Some studies have found that approximately 50% - 90% of patients who undergo fundoplication performed by an experienced surgeon have successful relief from GERD symptoms and esophagus inflammation.

- While other studies have discovered that in more than 50% of cases, patients still require the use of GERD medications to control their remaining symptoms. However, medications are not always required on a regular basis and symptoms appear less severe.

- Although some studies have indicated that fundoplication surgery can improve symptoms in most patients, no study has yet been able to prove that fundoplication surgery can effectively maintain the long term healing of the esophagus or the prevention of acid reflux.

- Some studies have found that a small fraction of patients (about 10% – 20%) who have had the surgery, continue to have symptoms or develop new health complications that may or may not respond to medical treatment. Additionally, other patients who did not respond well to surgery required a second surgery within a decade of receiving the first, because of complications from the original operation.

Are there complications? Yes, complications can occur. Risk factors accompany any surgery or medical procedure. The complications that can occur after fundoplication surgery include:

- The risks of major surgery and anesthesia which can include breathing problems caused by the anesthetic, bleeding, and infection. Although rare, there have been incidences of patients who have had this surgery dying from surgical complications or anesthesia.

- Swallowing difficulty can occur because the stomach was been wrapped too tightly or too high on the esophagus. This is a complication more commonly found for those undergoing the laparoscopic procedure.

- The esophagus can slide out of the wrapped part of the stomach. If this occurs, the LES is no longer supported and acid reflux can reoccur.

- Heartburn returns

- Excess gas

- The inability to burp which causes a buildup of gas that results in bloating and other discomfort.

Finally, keep in mind that fundoplication cannot be reversed, and that not all complications can be fixed with a second surgery or medical treatment.

Are there medical alternatives to this surgery? Yes, there are alternatives including medications such as proton pump inhibitors that work to reduce stomach acid. This medication can be effective for many GERD sufferers.

Another alternative is endoscopic methods. An endoscope is a small, long flexible tube with a video camera that is swallowed by the patient so the doctor can view the inside of the esophagus. The endoscope also features different channels in which the doctor can insert various instruments to provide the necessary treatment. One endoscopic method is called the Stretta procedure, which is designed to tighten the LES through the use of an electric current.

Who is eligible for fundoplication surgery? This surgery is primarily recommended for GERD suffers who have severe heartburn/acid reflux that does not respond to medications or natural treatments such as lifestyle changes or herbal/alternative remedies. Surgery is also recommended for those who suffer from:

- Erosive esophagitis - Severe inflammation of the esophagus caused by acid reflux
- Esophageal stricture – narrowing of the esophagus caused by acid reflux
- Para-esophageal hernia – the upper part of the stomach protrudes through the opening of the diaphragm (hiatal hernia)
- Chronic lung inflammation (I.E. pneumonia) that results from inhaling gastric fluids that backup into the throat

Who is not eligible for fundoplication? Not everyone is a candidate for fundoplication surgery. Those who cannot undergo fundoplication include:

- Older adults with additional health problems to GERD
- Those who have unusual symptoms that could worsen with surgery such as weak peristalsis (food moves too slowly down the esophagus to the stomach)
- Esophageal cancer or suspected cancer of the esophagus
- Pregnancy

Others who can experience surgical difficulties that may exclude them from fundoplication include those with:
- A shortened esophagus
- Previous extensive surgery involving the upper abdomen
- Extreme obesity

What is the cost of fundoplication surgery? The cost of fundoplication surgery can range anywhere from $4,000 to $15,000. The cost will vary depending on different factors such as:
- If you will be undergoing laparoscopic or open surgery
- Where you have the surgery
- If complications occur
- How long you remain in the hospital
- Medications or follow-up treatments that may be prescribed after surgery

Does insurance pay for the surgery? Most insurance companies, such as Medicare, cover surgical treatment for GERD. However, it is imperative that you check with your insurance company first. This is important because you not only need to find out if you are covered, but also if there is a limit on coverage. You also need to obtain authorization from your insurance company prior to treatment.

If you believe you may be able to benefit from fundoplication surgery as a form of acid reflux treatment discuss your options with your doctor.

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