Minimally Invasive Esophageal Procedures

Marco G. Patti, MD, FACS

Disclosures

August 30, 2005

Laparoscopic Partial (Guarner) Fundoplication

Preoperative evaluation and operative planning are essentially the same for partial (Guarner) fundoplication as for Nissen fundoplication. This operation should be performed only in patients with the most severe abnormalities of esophageal peristalsis: it is less effective than a 360º wrap for long-term control of reflux.[9] In addition, laparoscopic partial fundoplication may be performed after laparoscopic Heller myotomy for achalasia (see "Laparoscopic Heller Myotomy with Partial Fundoplication").[24]

The first seven steps in a Guarner fundoplication are identical to the first seven in a Nissen fundoplication. The wrap, however, differs in that it extends around only 240º to 280º of the esophageal circumference. Once the gastric fundus is delivered under the esophagus, the two sides are not approximated over the esophagus. Instead, 80º to 120º of the anterior esophagus is left uncovered, and each of the two sides of the wrap (right and left) is separately affixed to the esophagus with three 2-0 silk sutures, with each stitch including the muscle layer of the esophageal wall. The remaining stitches (i.e., the coronal stitches and the stitch between the right side of the wrap and the closed crura) are identical to those placed in a Nissen fundoplication.

Currently, my average operating time for a laparoscopic fundoplication is approximately 2 hours. I start patients on a soft mechanical diet on the morning of postoperative day 1 and usually discharge them after 23 to 48 hours. The recovery time usually ranges from 10 to 14 days.

The initial results of laparoscopic fundoplication obtained in the early 1990s indicated that the operation was effective in controlling reflux but that postoperative dysphagia occurred more often than had been anticipated.[8] Many experts thought that this problem could be avoided by tailoring the fundoplication to the strength of esophageal peristalsis as measured by esophageal manometry.[8] Accordingly, partial fundoplication (240º) was recommended for patients with impaired peristalsis, and total fundoplication (360º) was recommended for those with normal peristalsis. The short-term results of this tailored approach were promising.[8] Gradually, however, it became evident that partial fundoplication was not as durable as total fundoplication[9] and that total fundoplication did not pose a special problem for patients with weak peristalsis.[25]

Long-term follow-up of patients operated on in accordance with the tailored approach at UCSF between October 1992 and December 1999 indicated that the promising short-term results reported earlier[8] were not maintained over time.[20] After a mean follow-up period of 70 months, 56% of the patients who underwent partial fundoplication had recurrent reflux as documented by pH monitoring, compared with only 28% of those who underwent total fundoplication. (These figures probably overestimate the real incidence of postoperative reflux, in that most of the patients studied had heartburn and very few were asymptomatic.) In addition, more of the patients in the partial fundoplication group needed acid-suppressing medication (25% versus 8%) or a second operation (9% versus 3%). The incidence of postoperative dysphagia, however, was the same in the two groups, which indicated that the completeness of the wrap played no role in causing this largely transient complication. These findings suggest that the initial problems with postoperative dysphagia were primarily attributable to unknown technical factors that were largely eliminated from the procedure as surgeons garnered more experience with it. As a result, total fundoplication is currently considered the procedure of choice for patients with GERD, regardless of the strength of their esophageal peristalsis.

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