Partial versus complete fundoplication: is there a correct answer?

Abstract

Gastroesophageal reflux disease is a common disorder, and patients diagnosed with GERD face a lifelong treatment requirement. A surgical antireflux procedure may be offered as an alternative to lifelong treatment with proton-pump inhibitors. Many investigations have been performed to help discover the best surgical alternative to medical management. An ideal antireflux procedure should be safe, effective, durable, and result in minimal complications. Total fundoplication in the form of Nissen fundoplication is the most widely used antireflux operation worldwide. Although its efficacy is well documented, the clinical success rate in terms of reflux control is occasionally compromised by troublesome mechanical side effects. Because of these unsatisfactory symptoms and continued hindered quality of life, the Nissen fundoplication has undergone many modifications. The current standard appears to be the 2 cm floppy Nissen; however, the alternative approach has been the use of a partial fundoplication, most frequently the Toupet procedure. Both the Nissen and Toupet fundoplications have proven to provide relief in the majority of patients, but each has its own drawback. Patients undergoing Nissen fundoplication have a higher incidence of dysphagia early after operation, although this appears to resolve in most. The Toupet, on the other hand, may not be as durable, and may lead to the early re-emergence of symptoms. The problem of post-Nissen dysphagia led many surgeons to believe that the Nissen night be contraindicated in patients who have dysmotility,because it would cause even greater dysphagia; however, recent articles have not demonstrated this to be the case. It seems that the floppy Nissen performed over a large bougie (56-60 Fr) with division of short gastrics and crural closure is an acceptable operation for reflux in both those who have normal motility and those who have mild to moderate dysmotility. Thus, for most patients who have GERD and normal motility, either procedure appears effective in the majority of patients; however, those patients who have severe dysmotilty disorders and who require an antireflux procedure(ie, scleroderma, postmyotomy achalasia) are likely best served with a partial fundoplication.