In a fundoplication, a fold (= sleeve) of gastric mucosa is sutured around the stomach entrance.
Fundoplication is a surgical procedure to treat heartburn, which is now usually performed using minimally invasive techniques. The medical term for this is gastroesophageal reflux disease ("GERD" from gastroesophageal reflux disease). This causes acidic stomach contents to flow back into the oesophagus, resulting in burning pain = heartburn. Fundoplication narrows the entrance to the stomach so that no more acidic chyme can flow back.
Illustration of reflux disease, in which stomach contents flow back into the oesophagus © bilderzwerg | AdobeStock
However, surgical treatment of reflux disease is rarely necessary. In most cases, treatment with medication is sufficient. Patients then regularly take proton pump blockers (=PPI, such as pantoprazole, omeprazole, etc.).
For a small proportion of patients, the symptoms improve initially, but cannot be eliminated permanently. Sometimes the heartburn can be treated, but not the reflux of food into the oesophagus. In some cases, the reflux may extend into the mouth or airways.
This symptom cannot usually be completely eliminated with medication. The reflux of food can also cause chronic bronchitis and severe lung disease, in which case it is highly recommended to see a specialist to discuss the possibility and necessity of a fundoplication.
Fundoplication was first published in 1956 by the surgeon Rudolf Nissen. He had developed and scientifically investigated the procedure over many years. The surgical procedure has been modified many times since then. Among other things, the procedure is no longer performed through a large abdominal incision (laparotomy), but by means of laparoscopy or "keyhole surgery" (medical term: laparoscopy). However, the basic principle of the operation is considered the unsurpassed standard for the gentle narrowing of the stomach entrance (so-called anti-reflux surgery) for the treatment of reflux disease.
Fundoplication is also used for other conditions in the entrance area of the stomach, such as hiatal hernia (where parts of the stomach move up and down through the diaphragmatic gap next to the oesophagus) or achalasia (where there is a movement disorder of the oesophagus, particularly at the lower end and entrance to the stomach).
Gastroscopy is one of the basic examinations for reflux disease. In addition to the gastric mucosa, the adjacent areas (oesophagus and duodenum) are also examined. It is important to rule out inflammation and, in particular, areas suspected of being tumorous.
This includes manometry ("pressure measurement") in the oesophagus(oesophageal manometry) and at the entrance to the stomach. This allows the force of the peristaltic wave with which the food is transported into the stomach to be determined. A disruption of these movements can be a major cause of reflux disease. It would also influence the surgical procedure.
Functional diagnostics of the oesophagus also include pH-metry. This is a measurement of the pH value in the oesophagus. It is usually carried out with a thin probe over a period of at least 24 hours. The intensity and frequency of "acid reflux" into the oesophagus during a normal daily routine are then determined. This is also important in order to justify the necessity of the operation.
In the past, an X-ray examination with contrast medium (so-called barium porridge) was common. Barium sulphate is a contrast medium and does not allow X-rays to pass through. It is odorless and tasteless and is ingested as a gruel. X-rays are then taken in different directions to visualize the movement of the chyme.
This examination can be carried out before and after the operation. Before, to justify the operation and plan the chosen technique, after, to ensure the result and rule out complications.
Nowadays, fundoplication is usually performed laparoscopically (i.e. via laparoscopy). This requires 4 to 5 small incisions in the upper abdomen.
If necessary, especially in the case of multiple previous operations, an open surgical procedure is also possible.
Fundoplication involves the loose "gathering" (lat. plicatio) and fixation of the upper parts of the stomach (lat. fundus). The body's own material is used to create a sleeve. It serves as a valve and supports the sphincter muscle at the entrance to the stomach. When the stomach fills up while eating, pressure builds up in the cuff around the oesophagus. This prevents the stomach contents from flowing back into the oesophagus.
There is a posterior fundoplication, in which the sleeve is pulled around the oesophagus from behind, and an anterior one from the front. In Germany, the posterior fundoplication is usually used, including the fundoplication according to Toupet (gastric sleeve is placed partially (270°)) and according to Nissen (completely (360°)) around the entrance to the stomach.
Fundoplication according to Nissen © Alila Medical Media | AdobeStock
A successful fundoplication usually leads to the immediate disappearance of reflux symptoms, including heartburn. It is then no longer necessary to take tablets.
As a rule, a laparoscopic fundoplication requires a hospital stay of around 2-5 days. It is important to check the surgical wounds and educate the patient. They must develop an awareness of what changes have been made to the stomach. The doctors have practically placed a "threshold" in the "door" to the stomach, which you will inevitably "trip over" if you don't think about it!
It is therefore essential to adjust your eating habits accordingly. This means above all
Once the air has reached the stomach, it is very difficult for it to escape. Belching and vomiting are hardly possible, especially in the first few weeks after the fundoplication. However, this is less frequent and less pronounced with fundoplication using the toupee technique than after Nissen plastic surgery. In the initial phase after the operation, however, carbonated drinks and flatulent foods should be avoided. The tolerance of different foods varies greatly from person to person and must be tested by each patient.
If the patient adapts to this and follows these rules, they will benefit from the absence of reflux symptoms and heartburn. Nevertheless, for most patients this means a significant improvement in quality of life, as many drinks (orange juice, coffee, red wine...) or foods (sweets, roasted meat) become edible again.
As with any operation, complications can occur during and after a fundoplication. On the one hand, there are general risks that are relevant to most abdominal procedures.
These include injury to the
This can result in further complications, such as bleeding during or after the fundoplication. An injury to the esophageal wall must be recognized immediately and treated safely. Otherwise there is a risk of serious infection with a life-threatening inflammatory reaction. However, these extremely serious complications are extremely rare if the procedure is carried out carefully and the surgeon is experienced.
Less serious problems, such as
also occur only rarely.
Some patients report changes in digestion even when the above-mentioned instructions on food intake are followed. These include an increased tendency to bloating or occasional diarrhea. However, these symptoms can usually be controlled by diet or short-term medication.
Heavy lifting and straining can have an unfavorable effect on the healing of the fundoplication.
Severe and persistent coughing attacks and severe vomiting also put a considerable strain on the surgical site later on. This can lead to the cuff opening again or being displaced into the chest.
In summary, fundoplication is a surgical procedure with good short and long-term results and a low risk of complications.
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