Partial fundoplications for gastroesophageal reflux disease: Indications and current status

The Nissen fundoplication, and in particular the laparoscopic Nissen fundop lication, has received widespread acceptance as the most definitive therapy for gastroesophageal reflux disease. There remains, however, certain patie nts who do better with a less aggressive surgical augmentation of the lower esophageal sphincter. Partial fundoplications originated in the early 1960 s as an alternative procedure to the Nissen, which was associated with mode rately high rates of postoperative side effects. These "more physiologic" p rocedures have proved successful in the treatment of reflux disease in pati ents with poor or no esophageal motility. In particular, the use of partial fundoplications in association with Heller's myotomy for achalasia has bee n demonstrated to be well tolerated and to reduce the risk of late dysphasi a resulting from uncontrolled gastroesophageal reflux (GER). The use of par tial fundoplications in GER patients with normal motility, however, has bee n less successful. High recurrence rates are documented by many centers wit h the main cause appearing to be related to a less competent neo-lower esop hageal sphincter and a higher rate of wrap herniation. This has led to the current practice of a "tailored approach" to reflux disease, in which all p atients receive a thorough preoperative physiologic evaluation to determine the best antireflux procedure for the individual. This is generally a Niss en repair for those with normal motility and either an extrashort "floppy" Nissen or a partial wrap for those with impaired peristalsis.