Fundoplication
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.
The Surgical Principle
The upper part of the stomach is detached from the spleen and the diaphragm.
The mobilized portion of the stomach is then wrapped around the esophagus and tightened.
👉 This leads to a narrowing of the esophagus.
Classical procedures include:
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Nissen fundoplication (360°)
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Toupet fundoplication (270°)
Various modifications:
Due to less than convincing long-term results, numerous variations have been developed over the years (e.g., Dor fundoplication, Rossetti fundoplication, Hill repair, Belsey Mark IV procedure, Thal fundoplication, among others), differing in suturing technique and type of wrap.
Typical Problems
This principle of wrapping can lead to functional limitations:
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difficulty or inability to belch
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gas retention with bloating and pressure
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reduced or absent ability to vomit
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recurrence of diaphragmatic disruption (hernia recurrence)
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some patients require proton pump inhibitors (PPIs) again
Clinical Perspective
These aspects explain why many physicians remain cautious about surgical intervention and often prefer medical therapy, despite significant patient burden.
Other Anti-Reflux Procedures
Bicorn Procedure
The Bicorn procedure is a form of limited fundoplication, performed by Dr. med. Bernd Ablassmaier, who has the greatest experience with this surgical technique.
In this procedure, the upper part of the stomach is sutured to the esophagus in such a way that a double (“bicorn”) tissue structure is created, intended to restore the angle of Hiss.
Additionally, the diaphragm is closed with sutures.
👉 Respectable results
RefluxStop™
A newer approach with a different concept.
A small ball 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.
👉 Long-term results are not available; increasingly considered obsolete.
EndoStim®
Electrodes are surgically attached to the esophagus and connected to a battery-powered pulse generator implanted in the abdominal wall. This is intended to stimulate the musculature to promote closure. Surgical battery replacement is required after several years.
👉 Outcome: No lasting benefit; the procedure is now regarded as obsolete.
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.
👉 The procedure ist considered obsolete.
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:
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limitations for MRI diagnostics
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mechanical narrowing of the junction
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slipping into the Thorax
👉 Long-term outcomes are affected by the need for device removal in some patients. The procedure is still performed, largely because it is technically simple.
Stretta® and Enteryx® Procedures
To narrow the esophagus endoscopically from within.
In the Stretta procedure, radiofrequency energy is applied, whereas in the Enteryx procedure, toxic substances are injected into the esophageal wall.
The resulting severe tissue injury is intended to induce scarring and narrowing. In addition, nerves are destroyed, so that patients may no longer perceive reflux.
👉 Outcome: Severe complications.; obsolete.
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.
👉 The procedure ist considered obsolete.