Fundoplication is a type of surgery to correct problems with the lower esophageal sphincter (LES) associated with gastroesophageal reflux disease (GERD).

The procedure involves wrapping a portion of the stomach either partially or completely around the band of muscles at the base of the esophagus. This strengthens LES muscles, allowing the LES to properly close and preventing contents of the stomach from backing up into the esophagus (reflux).

Fundoplication is most often used to treat patients with GERD and associated conditions, such as esophagitis and hiatal hernia. Patients with complications of GERD, such as stricture and Barrett’s esophagus (that has not progressed to cancer) may also benefit from fundoplication.

The surgery is often recommended for patients whose symptoms do not respond to lifestyle modification (e.g., diet, exercise) or medications. Patients may opt for fundoplication to avoid a lifetime of anti-reflux medication, or they may be unable to tolerate such medication.

Fundoplication may be performed as an open surgery, in which organs are manipulated directly via an opening several inches long in the patient’s abdomen or chest. However, most are now performed laparoscopically, through the insertion of tools through several small (1 centimeter) incisions in the patient’s abdomen or chest. Laparoscopic fundoplications involve a shorter hospital stay, a shorter recovery period and less scarring than open procedures. Patients often experience less postoperative discomfort with laparoscopic surgery as well.

Patients may undergo various tests (e.g., blood tests, x-rays) to monitor their overall health and view the structure of their esophagus and stomach prior to surgery. They will be given general anesthesia which will put them to sleep for the procedure, which takes approximately two hours. Their vital signs will be monitored and if a hiatal hernia exists, it will be repaired during the procedure. Patients may remain in the hospital for up to three days (laparoscopic) or six days (open) following fundoplication, and may be fed through a feeding tube during that time.

Patients will require a liquid diet for the first week following the surgery. They will need to refrain from strenuous activity and arrange for follow-up care with their physician. Patients can usually return to work within three weeks (laparoscopic) or six weeks (open) of the surgery.

Fundoplication reduces or eliminates GERD symptoms in the majority of patients who undergo the surgery. Estimates vary, but most patients experience relief after fundoplication.

Any type of surgery carries risks, including bleeding and infection. Adverse reactions to anesthesia may also occur. With fundoplication, patients may experience postoperative symptoms such as gas-bloat syndrome (inability to belch or vomit) and dysphagia (difficulty swallowing). In addition, GERD symptoms may recur after surgery. In those cases, patients may require anti-reflux medications or additional surgery. Fundoplication does not prevent the risk of cancer for patients with GERD and Barrett’s esophagus.

Nonsurgical alternatives to fundoplication are available. One involves stitching the LES to reinforce it. Another involves creating scar tissue to strengthen LES muscles. Both may be performed in outpatient treatment facilities and involve the use of an endoscope, rather than incisions to a patient’s body.

Fundoplication is a surgical procedure in which the fundus (uppermost portion) of the stomach is wrapped around the lower esophagus to strengthen the lower esophageal sphincter (LES) muscles and prevent acid reflux. The fundus of the stomach is used as a wrap because both it and the LES relax with swallowing.

Food enters the body through the mouth and travels through the esophagus before entering the stomach. The presence of food in the esophagus triggers the LES muscles to relax, allowing the food to pass into the stomach. The LES then closes to prevent stomach acid and contents from washing back up into the esophagus. In this way, the LES works as a one-way valve that aids digestion.

When LES muscles are unable to sufficiently tighten, the LES fails to properly close and stomach acid may travel back up into the esophagus, causing irritation and inflammation of the lining of the esophagus. When this occurs repeatedly, the condition is known as gastroesophageal reflux disease (GERD). 

A fundoplication procedure is most commonly performed on patients with GERD. It may also be performed on patients with esophagitis (inflammation of the esophagus) and is sometimes used to repair a hiatal hernia, a condition in which a portion of the stomach protrudes into the chest cavity through an opening in the diaphragm (a muscle that separates the chest from the abdomen).

Hiatal hernias are often associated with GERD and esophagitis, and may worsen the symptoms of those conditions. If a hiatal hernia exists, it is pulled down from the chest during a fundoplication, and the area of the diaphragm where the stomach protruded into the esophagus is tightened to prevent recurrence.

Fundoplication is often performed on patients who have developed complications from GERD or esophagitis, such as stricture (narrowing of the esophagus) or Barrett’s esophagus (precancerous condition that affects cells that line the esophagus). It may also be performed on patients suffering from reflux-induced airway problems. These include asthma-like symptoms such as difficulty breathing or pneumonia caused by gastric fluids being inhaled into the lungs.

Surgery may be recommended for patients who have not responded to other treatments, such as lifestyle modifications (e.g., diet, exercise) and medications. Some patients choose to have fundoplication as an alternative to lifelong use of GERD medications or because they cannot tolerate GERD medications.

Fundoplication may not be an option for the elderly, who face increased risk of injury or death during surgery. It also may not be appropriate for patients with existing problems (e.g., bloating, impaired movement of food through the esophagus) that may be worsened with surgery.

Fundoplication may be performed as a traditional (open) surgery in which the surgeon makes an incision several inches long in the abdominal area before conducting the procedure. It may also be performed laparoscopically. This involves making several tiny incisions in the abdomen before inserting a laparoscope (a thin, lighted tube with a tiny camera attached to it) through one of them. Laparoscopic fundoplication, when performed by experienced surgeons, is reported to be as safe and effective as open fundoplication.

Most fundoplication procedures performed today are conducted laparoscopically because the recovery time is shorter than with traditional surgeries and there is less scarring and less postoperative discomfort. However, open surgery may be required in cases in which a physician has difficulty visualizing or handling organs effectively.

Whether open or laparoscopic, incisions made during a fundoplication are sometimes made through the chest instead of the abdomen. This may occur for a number of reasons, including cases of obesity, a shorter than normal esophageal length or extensive prior surgeries.

Fundoplication can involve a complete (360 degree) or partial (varying degrees) wrap of the lower esophageal sphincter (LES). In addition, variations may occur during surgery, including differences in the tightness, completeness or length of the wrap. The most common types of fundoplication are:

• Nissen fundoplication. This is the most commonly performed fundoplication. It involves wrapping a portion of the stomach completely (360 degrees) around the base of the esophagus, significantly increasing LES muscle pressure. Postoperative symptoms, such as gas-bloat syndrome, occur more often with this type of fundoplication. This procedure is recommended for patients with normal esophageal length and no existing motility problems within the esophagus.
  
  
• Toupet fundoplication. This procedure involves a partial wrapping (usually 180 to 200 degrees) around the LES. This partial wrap appears to control reflux as well a complete (Nissen) wrap, but has the added benefit of reducing the likelihood of common postoperative symptoms (e.g., gas-bloat syndrome). It is recommended for patients with normal esophageal length and decreased motility within the esophagus (to prevent worsening of this condition after surgery).
  
  
• Belsey Mark IV fundoplication. This partial wrap involves reinforcing 270 degrees of the circumference of the LES. This procedure is performed through the chest rather than the abdomen. It is recommended for patients who may benefit from this point of entry (e.g., obese patients, patients with a shorter-than-normal esophagus) and who currently experience decreased motility within the esophagus.   

A modified version of open or laparoscopic fundoplication, known as endoluminal fundoplication (ELF), involves accessing the stomach though the mouth, which eliminates the need for incisions. This technique is currently being practiced in the European Union, but has not been approved by the U.S. Food and Drug Administration.

There is no one operation that works best for all patients. Factors that may play a role in determining a fundoplication type include previous surgeries, problems with the movement of food within the esophagus, length of the patient’s esophagus, patient’s body weight and available surgical expertise. Patients should consult their physician about which approach is most appropriate to treat their condition.

Before the fundoplication procedure is performed, patients may undergo tests, such as blood tests and electrocardiogram (EKG) readings to monitor their overall health. An upper GI series (x-rays of the stomach and esophagus) can identify esophageal length and degree of hiatal herniation, if any, which may be helpful prior to surgery. Endoscopy is used to determine the degree of esophagitis, including possible Barrett’s esophagus.

Manometry tests, which measure the ability of muscles within the esophagus to work properly, may be useful in identifying or confirming a particular surgical approach or other form of treatment. They may also be used to identify reflux as the cause of a patient’s symptoms, as well as rule out other potential causes, such as scleroderma (skin hardening that may affect internal organs) or achalasia (disorder that causes the lower esophageal sphincter [LES] to remain closed, preventing food from reaching the stomach). 

Prior to surgery, patients may be required to discontinue use of certain medications. They must also refrain from eating for at least eight hours before the surgery.

Fundoplication takes place in a hospital. Shortly before the procedure, a patient is given drugs or a gas that puts them to sleep. This is called general anesthesia. An intravenous (I.V.) line that delivers fluids is placed in the patient’s vein and the patient is wheeled into the operating room.

During surgery, the patient’s vital signs are monitored with special devices. Heart rate is monitored by EKG leads placed on the patient’s body, breathing is monitored with an oxygen mask and blood pressure is monitored with a blood pressure cuff.

If the surgery is being performed as open surgery, the surgeon will make an incision several inches long in the middle of the abdomen or chest. Instruments are used to keep the incision open so the surgeon can view the areas of the body undergoing surgery.

If the surgery is being performed laparoscopically, several small incisions (about 1 centimeter in length) are made in the abdomen or chest. With laparoscopic surgery, a laparoscope (thin, lighted tube with a tiny video camera) is inserted into one of the incisions. Instruments that hold open and move the parts of the body involved in the surgery are placed in the remaining incisions.

Fundoplication typically requires two hours to complete. Whether the surgery is open or performed laparoscopically, the surgeon uses special instruments to wrap the fundus (uppermost portion) of the stomach in a circle, either partially or completely around the lower part of the esophagus. The wrapped portion of the stomach is kept in place with stitches.

The wrapped portion of the stomach strengthens the lower esophagus. This prevents reflux by increasing pressure on the LES muscles so they do not relax and allow stomach contents to wash back into the esophagus.

In patients with hiatal hernias (protrusion of the stomach into the chest through a hole in the diaphragm), the hernia is repaired.

The time required to recover from fundoplication depends on whether it was performed as open surgery or laparoscopically. Patients who receive open surgery may be required to stay in the hospital for two to six days. Patients who undergo laparoscopic surgery typically stay in the hospital for one to three days.

While in the hospital, patients may have a feeding tube (nasoenteral tube) inserted into their stomach through the nose and throat. This may remain in place for a few days.

After patients return home, a number of steps must be taken during postoperative recovery. They include:

• Diet modification. Patients that undergo fundoplication typically follow a liquid diet for one week after the surgery. This may include any type of food or drink that travels smoothly through the esophagus into the stomach, including soup, mashed potatoes, milkshakes or foods that have been pureed. When a physician recommends shifting to a solid food diet, patients may wish to avoid those foods that are difficult to swallow or cause gas.
  
  
• Medications. Depending on physician advice, patients may continue to take their anti-reflux medications for a month following surgery. Patients may use prescription or over-the-counter medications for pain relief. Patients may want to obtain pain medication in liquid form, if possible.
  
  
• Wound care. Dressings may be used to protect wounds after open surgery. Wounds are kept moist with an ointment that is covered by a bandage, which promotes healing. The bandage may need to be frequently changed to prevent bacteria from becoming trapped in the wound and causing infection.
  
  With laparoscopic surgery, stitches are placed just below the surface of the incision. They are absorbed by the body and do not require removal. Patients should keep the incision sites clean by washing them with soap and water, rinsing them thoroughly and gently patting them dry.
  
  
• Activity restriction. Patients should not lift heavy objects for the first few weeks after surgery. Patients may usually return to driving within a week of surgery, although they should not drive while taking pain medication. Patients may return to walking and going up and down staircases, but they should avoid strenuous exercises that affect the abdomen (e.g., sit-ups, weight lifting) for six weeks.
  
  
• Medical follow-up. Patients should make an appointment to see their physician within the recommended timeframe.

Patients who experience any of the following symptoms should contact their physician immediately since these may indicate a complication of surgery:

• Persistent nausea and vomiting
• Persistent or increasing pain
• Redness or pus at the wound site
• Fever greater than 101 degrees Fahrenheit (38.3 degrees Celsius)

If a piece of food gets stuck in the esophagus, it is recommended that patients recovering from fundoplication attempt to gently wash it into the stomach by slowly drinking warm water. If the food remains lodged, patients are advised to contact their physician immediately.

Patients who undergo open fundoplication are usually able to return to work within four to six weeks. Patients who undergo laparoscopic fundoplication may typically return to work within two to three weeks.

The biggest potential benefit of fundoplication is relief of gastroesophageal reflux disease (GERD) symptoms. Estimates vary, but it appears that 85 to 95 percent of patients achieve reduction or elimination of symptoms after fundoplication.

However, there are risks involved with any type of surgery performed under anesthesia. These include:

• Bleeding
  
• Infection
  
• Adverse reactions (e.g., breathing or heart problems) to anesthesia

In addition, patients who have undergone fundoplication may experience the following after surgery:

• Gas-bloat syndrome. The inability to belch or vomit to relieve bloating or nausea. Approximately 40 percent of patients undergoing a fundoplication procedure experience gas bloat syndrome, according to the National Institutes of Health (NIH). It generally improves over time, although in rare cases it may be long-lasting.
  
  
• Dysphagia. Pain or difficulty swallowing. According to NIH, anywhere from 5 to 40 percent of patients undergoing fundoplication experience dysphagia. In almost all cases, it improves within three months of the surgery. Patients with dysphagia prior to surgery have an increased risk of experiencing it after surgery. Dysphagia appears to occur more often among patients who have undergone laparoscopic fundoplications rather than open surgery. This may be related to difficulty determining the looseness of the wrap with a laparoscope.
  
  
• Recurrence of original symptoms/conditions. Some patients may experience a return of their GERD symptoms (e.g., heartburn due to acid reflux), even after fundoplication. A hiatal hernia (protrusion of part of the stomach into the chest area) may also recur after surgery. Treating these recurrences may require anti-reflux medications or additional surgery.
  
  
• Diarrhea. Loose, watery stool. This may be the result of the quick movement of food through the digestive tract that can occur after surgery. Diarrhea usually goes away within three months of surgery.
  
  
• Gas. Increased levels of gas in the abdomen can also cause increased flatulence in patients recovering from fundoplication. These symptoms generally diminish over time.
  
  
• Feeling full after eating small amounts of food. This sensation usually goes away within three months after fundoplication.
  
  
• Damage to stomach or esophagus. This may occur if the surgery is not performed correctly, or if the stomach or esophagus is punctured during surgery. The risk of this sort of complication as a result of fundoplication is rare.

Fundoplication does not eliminate the risk of cancer for patients with GERD and Barrett’s esophagus. It also does not eliminate the need for GERD medications. Up to half of all fundoplication patients may continue to require anti-reflux medications to manage their symptoms after surgery.

There are several alternatives to fundoplication for the treatment of gastroesophageal reflux disease (GERD).

Non-surgical techniques offer a convenient and minimally invasive approach to treating GERD symptoms. Also, they do not preclude surgery. Surgical treatment options, such as fundoplication, may be pursued later should GERD symptoms recur.

Two non-surgical anti-reflux techniques involve the use of an endoscope (a thin, flexible tube with light and camera that is inserted into the esophagus through the mouth). Neither technique involves incisions into a patient’s body. Both may be performed in outpatient medical facilities. However, the long-term ability of these techniques to keep GERD symptoms in remission is unknown. They are:

• Endoluminal gastroplication. Procedure in which stitches are made in the lower esophagus, forming pleats in the lower esophageal sphincter (LES) muscles. This helps strengthen LES muscles and reduces the ability of stomach acid to wash back up into the esophagus. Physicians lower the sewing devices into the esophagus via an endoscope.
  
  
• Radiofrequency treatment for GERD. Procedure in which electrodes direct radiofrequency energy at the lower esophagus to melt tissue in that area. The resulting scar tissue appears to help toughen LES muscles to prevent reflux. Sensory nerves that respond to reflux by opening or closing the LES may also be affected.

The effectiveness and risks of these procedures have not been extensively studied. They have been used on a relatively small number of patients with comparatively mild, uncomplicated cases of GERD.

Another non-surgical procedure, the Enteryx implant, is no longer performed due to safety concerns. In this procedure, a physician injects a type of bulking material into the muscle wall of the LES. Once injected, it thickens into a spongy material that helps prevent acid reflux. Enteryx received approval from the U.S. Food and Drug Administration in 2003, but it has since been recalled due to reports that improper injection (e.g., penetrating the esophagus or nearby vital organs) can cause serious patient injury and death.

A surgical procedure that may be performed to treat GERD is a Hill gastropexy. This involves stitching the stomach into position to prevent its displacement (e.g., a hiatal hernia), which can lead to or worsen GERD symptoms. A Hill gastropexy may be performed instead of or in addition to a fundoplication. This procedure may be used for patients with a small stomach due to prior gastrectomy surgery.  

An angelchik prosthesis is a donut-shaped ring that is surgically implanted at the base of the esophagus to tighten the area and reduce reflux. This procedure is rarely used due to a high rate of complications, especially mechanical problems with the device (such as its movement after implantation).

Preparing questions in advance can help patients to have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions related to fundoplication:

1. Am I a candidate for fundoplication?
   
   
2. What type of fundoplication will best treat my condition?
   
   
3. Are there other surgical options available to me?  What about non-surgical treatment options?
   
   
4. If you recommend a fundoplication, should I have an open or laparoscopic surgery? What are the risks and benefits of each?
   
   
5. What tests may be necessary before my surgery?
   
   
6. Which prescription or nonprescription medications that I currently take should I discontinue prior to surgery?
   
   
7. How long will my surgery last?
   
   
8. Will I experience pain after surgery? Are there specific prescription or nonprescription medications I should take (or avoid) for this pain?
   
   
9. What steps should I take to care for my wound?
   
   
10. What follow-up care will be required?
    
    
11. Will I need to continue taking my current anti-reflux medications after the surgery?  If so, for how long?
    
    
12. What diet or lifestyle modifications will I need to make after surgery?
    
    
13. How soon can I return to my normal routine after surgery?
    
    
14. What postsurgical symptoms should I report to you?