Nissen Fundoplication Procedure and Indications

Preoperative Evaluation and Patient Selection

The American College of Surgeons recommends that patients with pathologic GERD and severe esophagitis (LA Grade C or higher) who are uncontrollable with medical therapy should undergo Nissen fundoplication 1
The Society of American Gastrointestinal and Endoscopic Surgeons suggests that 24-hour multichannel intraluminal impedance-pH monitoring is the gold standard for confirming pathologic GERD 3, 2
Upper endoscopy with biopsies should be performed to document LA classification grade of erosive esophagitis and rule out complications, as recommended by the American Gastroenterological Association 1
High-resolution esophageal manometry should be used to assess peristaltic function and exclude achalasia or severe motility disorders, according to the American College of Gastroenterology 1
Barium swallow should be performed to identify hiatal hernia, strictures, or short esophagus before surgery, as suggested by the Society of Abdominal Radiology 3, 1

The American College of Surgeons recommends a laparoscopic approach for Nissen fundoplication, which has an excellent safety profile with an overall in-hospital mortality of 0.14% 1, 2
The wrap must be tension-free to prevent postoperative complications, as emphasized by the Society of American Gastrointestinal and Endoscopic Surgeons 1
Hiatal closure is essential to prevent wrap herniation and recurrent reflux, according to the American Hernia Society 1
Vagus nerve preservation during esophageal dissection is critical, as recommended by the American College of Surgeons 1

The American Academy of Pediatrics suggests that children with neurologic impairment, esophageal atresia-tracheoesophageal fistula repair history, diffuse motility disorders, chronic pulmonary disease, and young infants have significantly higher failure rates 2
Laparoscopic fundoplication is the recommended surgical approach for patients with esophageal atresia-tracheoesophageal fistula, according to the European Society for Pediatric Gastroenterology 3, 4
The choice between total (Nissen) or partial fundoplication should be left to surgeon expertise, though partial fundoplication should be strongly considered in patients with impaired esophageal peristalsis, as suggested by the American College of Surgeons 3, 2

Postoperative dysphagia affects 5-43% of patients and represents the most frequent complication, occurring more commonly after total fundoplication compared to partial wraps, according to the American College of Gastroenterology 2
Gas bloat syndrome is a common complication, where patients cannot belch or vomit effectively, with associated flatulence and early satiety, as reported by the American Gastroenterological Association 2
For persistent dysphagia post-fundoplication, upper GI endoscopy, manometry, pH studies, and barium swallow should be performed first to assess wrap integrity before considering revision, as recommended by the Society of American Gastrointestinal and Endoscopic Surgeons 2
Endoscopic surveillance is recommended to monitor healing and detect potential complications, particularly in patients with Barrett's esophagus or complex anatomy, according to the American Society for Gastrointestinal Endoscopy 2