Classical Anti-Reflux Surgery: Fundoplication

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Fundoplication is the oldest and most widely performed surgical procedure for the treatment of reflux disease.

It was developed nearly 100 years ago and follows a simple principle:
👉 If the natural closure mechanism fails, it is mechanically reinforced – by narrowing.

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The Surgical Principle

The upper part of the stomach, the so-called fundus, is mobilized from its natural attachments to the spleen and diaphragm.
This requires division of vessels and nerves in this area.

The mobilized stomach is then folded around the esophagus and fixed in place.

This creates a cuff that narrows the transition between esophagus and stomach.

Hence the name: fundoplication (Latin plica = fold)

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Different Variants

Due to not always convincing results, numerous variations of this technique have been developed.

The most important are:

• Nissen fundoplication (360°)
  complete wrap

• Toupet fundoplication (270°)
  partial wrap

• anterior fundoplication (e.g. Dor)
  technically simpler, but with less favorable long-term results

In addition, many other modifications exist (Rosetti, Hill, Belsey, Thal, etc.), differing in technique and degree of wrapping.

All of these procedures share one key principle:
👉 The esophagus is mechanically narrowed by a gastric wrap.

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Typical Problems

This principle of wrapping can lead to functional limitations:

• difficulty or inability to belch

• gas retention with bloating and pressure

• reduced or absent ability to vomit

• recurrence of diaphragmatic disruption (hernia recurrence)

For many patients, this represents a significant impairment in daily life.

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Long-Term Outcomes

Long-term results are not consistently satisfactory:

👉 Some patients require proton pump inhibitors (PPIs) again
👉 Symptoms may persist or recur

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Clinical Perspective

These aspects explain why many physicians remain cautious about surgical intervention and often prefer medical therapy, despite significant patient burden.

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Other Anti-Reflux Procedures

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Bicorn Procedure

The bicorn procedure is a modified form of fundoplication.

The upper part of the stomach is sutured to the esophagus in a way that creates a double (“bicorn”) tissue configuration to reinforce the junction.
Additionally, the diaphragm is repaired.

As with other wrap-based techniques, similar functional limitations may occur—though often less pronounced.

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RefluxStop™

A newer approach with a different concept.

A small implant is placed in the stomach wall and fixed near the esophagus to stabilize the anatomical position of the gastroesophageal junction.

The closure mechanism is intended to improve indirectly, without wrapping the esophagus.

Long-term results are still limited.

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EndoStim®

This procedure uses electrical stimulation of the lower esophageal sphincter.

Electrodes are attached to the esophagus and connected to an implanted device.

👉 The system is battery-dependent and typically requires replacement after 7–10 years.

A clear and lasting clinical benefit has not yet been conclusively demonstrated.

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Angelchik Prosthesis

A silicone ring is placed around the esophagus to mechanically narrow the junction.

The aim was to simplify the surgical approach compared to fundoplication.

Due to complications, this procedure is now rarely used.

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LINX® System

A ring of magnetic beads is placed around the esophagus.

The magnets strengthen the closure mechanism while allowing opening during swallowing.

Points to consider:

• limitations for MRI diagnostics

• mechanical narrowing of the junction

Long-term outcomes are affected, among other factors, by the need for device removal in some patients.

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Stretta® and Enteryx® Procedures

These techniques aim to modify the esophagus from within.

Stretta® uses radiofrequency energy, while Enteryx® involved injection of substances into the esophageal wall.

The principle:
👉 controlled tissue injury leads to scarring and functional narrowing.

In addition, damage to sensory nerves may reduce the perception of reflux.

Results have been inconsistent; Enteryx® was withdrawn from the market due to complications.

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TIF® (Transoral Incisionless Fundoplication)

This approach attempts to perform a fundoplication endoscopically.

Instruments introduced through the mouth are used to create and fix tissue folds in the stomach to reinforce the junction.

Important structures such as the vagus nerve or blood vessels cannot be directly visualized.

Long-term results remain limited.