Reviewed by DR. D. DATTA.
Ex. Emergency Medical Officer.
Fundoplication is the most common surgical procedure done to prevent acid reflux from the stomach to the esophagus in gastroesophageal reflux disease (esophagus is a tube through which food or liquid goes to the stomach from the mouth).
[Read more about gastroesophageal reflux disease].
In this procedure the upper portion (fundus) of the stomach is wrapped around the lower portion of the esophagus and sewed in place. As a result, the strength of lower esophageal sphincter increases and reflux of stomach content back into the esophagus is prevented (lower esophageal sphincter is a muscular valve at the junction of esophagus and stomach). A hiatus hernia if present may also be repaired at the same time.
By preventing gastroesophageal reflux disease (GERD) chances of Barrett’s esophagus and esophageal cancer can also be reduced.
[Read more about Barrett’s esophagus]
Indications of fundoplication
Gastroesophageal reflux disease can be treated by medications and lifestyle changes.
Fundoplication done
1 When acid reflux cannot be prevented by medications and lifestyle changes.
2 It may be done when there is severe inflammation of the esophagus due to acid reflux
3 If the patient cannot take medicines for some other reason.
4 To prevent Gastroesophageal reflux disease after Heller Myotomy operation for achalasia cardia.
[Read more about achalasia cardia]
Investigations before fundoplication operation-
Before fundoplication surgery the doctor may advise several investigations to see the condition of the esophagus and stomach.
1 Barium swallow x ray- Barium solution is swallowed; several x-rays are taken after drinking barium solution. The solution coats the inner lining of the esophagus. It can diagnose whether the esophagus is dilated or not and whether the food or liquid is passing through the esophagus in time or accumulates in the esophagus. It can also detect any filling defect in the esophagus.
2 Esophageal manometry- Here a catheter is inserted through the nose. It measures the force of esophageal muscle contraction, pressure of lower esophageal sphincter (LES), how LES relaxes and opens during swallowing. It can detect any motility disorder of the esophagus that may cause symptoms of gastroesophageal reflux disease.
3 Upper gastrointestinal endoscopy- A flexible tube mounted with light and camera (endoscope) can be passed through the mouth to visualize the esophagus, stomach and first part of small intestine (duodenum). It can assess the integrity of LES. Esophageal inflammation, ulcer, and stricture, dilatation of esophagus, presence of Barrett’s esophagus, gastritis, gastric ulcer, polyp, carcinoma can be seen. Tissue samples for biopsy can also be taken from the upper gastrointestinal tract for further studies.
4 24-hour pH test- a thin tube with sensor is passed through the patient’s nose into distal esophagus that can detect and record reflux of acid in esophagus from the stomach. This test is performed for 24 hours and the patient can do his normal activities during this time.
Preparation for fundoplication surgery
1 Tell your doctor if you are taking any medicine, you may need to stop some medicines such as blood thinner medicines before surgery
2 No food or drink after midnight the day before surgery.
3 Intravenous access done for giving injections for general anesthesia and intravenous fluids.
This procedure can be done by open abdominal surgery or laparoscopic surgery.
In laparoscopic surgery 4 to 5 small incisions are made in the abdomen through which light, camera and tools for performing the operation is passed. With the help of a screen the surgeon can see the field of operation and wrap the fundus of the stomach around the lower esophagus then closes the abdominal incisions with stitches.
Advantages of laparoscopic fundoplication surgery –
1 Less abdominal scar
2 Less pain and blood loss.
3 Short recovery time and shorter hospital stay. The patient can be released 36 to 48 hours after surgery.
In open abdominal surgery a large incision is made in the abdomen so that stomach and esophagus can be accessed directly. Surgeon wraps the fundus of the stomach around the lower esophagus then closes the abdominal incisions with stitches. You may need to stay one week at the hospital.
After fundoplication surgery a nasogastric tube is introduced to clear the stomach secretions. Nutrition is maintained through intravenous fluids until the patient can take food through the mouth. First, liquid, then soft food is given. Solid foods may be given after 3 to 4 weeks.
Outcome of fundoplication operationÂ
The procedure has a good success rate and long-lasting effect.
1 There is significant improvement of Quality of life of gastroesophageal reflux disease patients after fundoplication surgery.
2 Less or no requirement of medicines to suppress gastric acid secretion.
3 The patient usually returns to normal activity after 2 to 4 weeks.
Types of fundoplication operation
The surgeon can wrap the whole or part of the lower esophagus.
1 Nissen fundoplication (360-degree wrap)- here the whole of the lower end of the esophagus is wrapped by the fundus.
2 Toupet fundoplication (270-degree wrap)- here two thirds around the back of the lower part of the esophagus is wrapped by the fundus.
3 Watson or Dor fundoplication (180-degree wrap)- here half around the anterior portion of the lower end of the esophagus is wrapped by the fundus. There is less incidence of postoperative dysphagia and abdominal bloating in this procedure.
Side effects of fundoplication operation
1 Abdominal bloating,
2 Dysphagia (that may improve with time).
3 Difficulty in belching.
4 Infection in scar and surgical sites.
5 Reflux may not be controlled and may need further surgery.
When one should consult a doctor after fundoplication operation
You should consult your doctor if
1 There is bleeding from or discharge of pus from the incision site
2 Blood vomiting or bloody stool or black, tarry stool.
3 Difficulty in breathing
4 Chest pain
5 High grade fever
6 Sudden abdominal swelling
