Fundoplication

H. J. Stein, W. K. Kauer, H. Feussner and J. R. Siewert, Bile reflux in benign and malignant Barrett s esophagus effect of medical acid suppression and nissen fundoplication, J. Gastrointest. Surg., 1998, 2(4), 333. 

Omeprazole, in a starting dose of 0.7 mg/kg/day, was effective in the treatment of severe esophageal reflux after failed fundoplication in 18 children (mean age at presentation 7.8 years) over a mean follow-up period of 4.4 years (30). It was also well tolerated. A hyperplastic polyp was noted in one child after 38 months of treatment and persisted without any dysplastic change. One to three gastric nodules were seen in three children after a mean of 45 months histology of the nodules showed only mucosal edema. 

Pashankar D, Blair GK, Israel DM. Omeprazole maintenance therapy for gastroesophageal reflux disease after failure of fundoplication. J Pediatr Gastroenterol Nutr 2001 32(2) 145-9. 

Kuipers EJ, Lundefl L, Klinkenberg-Knol EC, et al. Atrophic gastritis and Helicobacter pylori infection in patients with reflux esophagitis treated with omeprazole or fundoplication. N Engl J Med 1996 334 1018-1022. 

Allen CJ, Anvari M (1998) Gastro-oesophageal reflux related cough and its response to laparoscopic fundoplication. Thorax 53 963-968... 

Fasulakis S, Andronikou S (2003) Balloon dilatation in children for esophageal strictures other than those due to primary repair of oesophageal atresia, interposition or restrictive fundoplication. Pediatr Radiol 33 682-687 Fernbach SK, Glass RBJ (1988) The expanded spectrum of limb anomalies in the VATER association. Pediatr Radiol 18 215-220... 

Hassal E (2005b) Outcomes of fundoplication causes for concern, newer options. Arch Dis Child 90 1047-1052 Herman TE, Oser AB, McAlister WH (1991) Tubular communicating duplications of esophagus and stomach. Pediatr Radiol 21 494-496... 

Gastric perforation beyond infancy in the pediatric population is also rare. It can be seen in cases of iatrogenic trauma (tubes and catheters), after Nissen or other fundoplications in patients with distal small bowel instruction, after caustic ingestion or in patients with blunt trauma to a distended stomach. Gastric rupture can also be seen in patients with perforated peptic ulcer and dermato-... 

Chapman WH, Young JA, Albrecht RJ, Kim VB, Nifong LW, Chitwood WR Jr (2001) Robotic Nissen fundoplication alternative surgical technique for the treatment of gastroesophageal reflux disease. J Laparoendosc Adv Surg Tech A 11 27-30... 

Rudolf Nissen, a peripatetic surgeon of Berlin, Istanbul, Boston, Brooklyn, and Basel, is best remembered for establishing fundoplication as the definitive surgical procedure for the management of GERD. Few recall that he operated on Albert Einstein. 

In general, the laparoscopic approach follows the same principles as the open Nissen fundoplication. A particular advantage is the excellent visibility of the gastroesophageal junction at operation and the relatively atraumatic nature of the procedure as compared to a major upper abdominal incision. A short (1 to 2 cm) wrap is advocated to avoid postoperative dysphagia. Other modifications that have been proposed include either division of the short gastric vessels to establish a tension-free fundoplication using a mobile posterior portion of the fundus or, alternatively, nondivision with the use of a more anterior portion of the fundus. 

Postfundoplication complaints after a total fundoplication. The ranges for each of these parameters are as follows dysphagia, 0% to 71% flatulence, 30% to 60% bloating, 1% to 38% and inability to belch, 4% to 80%. The ranges for the complication and relapse rates were 1.9% to 26.0% and 0% to 8.6%, respectively. (Adapted from Lundell L. Anti-reflux surgery in the laparoscopic era. Baillieres Best Pract Res Clin Gastroenterol 2000 14 793-810.)... 

A further issue that has been used to support the position of surgery has been the notional consideration that antireflux surgery should decrease health care use. A retrospective matched cohort study of Tennessee Medicaid patients compared the costs of medical and surgical treatment for GERD in 1996. The study compared 135 patients who had fundoplication with 250 randomly selected patients from a group of more than 7,000 who were treated medically. 

In the past, the acid infusion or Bernstein test was used to confirm the diagnosis, but for the most part, this has proven to be relatively insensitive and has been superseded by the use of esophageal pH monitoring. Once the diagnosis has been confirmed, treatment with PPIs has been shown to be effective in up to 85% of patients. In some centers, individuals have undergone fundoplication, with comparable resolution of symptomatology. 

The best management of asthma-related GERD involves aggressive acid suppression with PPIs, which not only significantly reduce the asthmatic episodes but also considerably improve pulmonary function in almost 80% of patients. In those individuals who underwent a fundoplication procedure, as many as 75% were cured or improved significantly. 

In the treatment of chronic GERD, laparoscopic fundoplication is (probably) as effective as and is less costly than open surgery and has a lower morbidity rate and almost no mortality. Surgery is associated with a substantial initial cost, accruing benefits over the ensuing years with minimal additional costs, making fundoplication an attractive long-term treatment option for some patient subsets. 

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