Laparoscopic Anti-reflux Surgery: Nissen and Partial Fundoplications

Anti-reflux surgery is the only cure for moderate to severe gastroesophageal reflux disease (GERD) that is unresponsive to medical therapy. Although most patients with GERD may present with acid reflux, heartburn, or chest pain, especial attention should be placed on those patients who present with laryngopharyngeal reflux (LPR) and atypical symptoms (hoarseness, laryngitis, nocturnal asthma, coughing, dental erosion), since it may represent up to half of the patients with GERD. The preoperative workup should include an upper gastrointestinal endoscopy (UGE), an esophageal manometry, and an esophagogastric video roentgenographic contrast study to assess esophageal length. The 24-h esophageal pH monitoring is usually reserved for those patients with negative UGE or present with atypical symptoms. The selection of a partial versus a complete fundoplication depends on the assessment of the esophageal contractility and the clinical presence of dysphagia. For those patients with normal esophageal length and motility, a laparoscopic Nissen fundoplication is our procedure of choice, whereas for those patients with decreased motility and dysphagia, our preference is to perform a Toupet fundoplication. Although no consensus exists on the best operative procedure, both procedures have demonstrated equivalent improvement in quality of life and long-term control of GERD.