Laparoscopic Fundoplication at World Laparoscopy Hospital

Laparoscopic Fundoplication
Symptoms
■ Heartburn (retrosternal burning)
■ Regurgitation
■ Pain
■ Respiratory symptoms
Diagnostic Test
■ Endoscopy
■ Barium swallow
■ Esophageal transit +/– manometry
■ pH monitoring
Treatment of Gastroesophageal
Reflux Disease
Medical therapy is the first line of management. Lifestyle
modification and medications are the first-line treatment
for GERD. Surgical management is generally reserved
for patients who have persistent symptoms or develop
complications despite optimal medical therapy. Esophagitis
will heal in approximately 90% of cases with intensive
medical therapy. However, symptoms recur in >80% of
cases within 1 year of drug withdrawal. Since, it is a chronic
condition, medical therapy involving acid suppression and/
or promotility agents may be required for the rest of patient’s
life. Despite the fact that current medical management is
very effective for the majority, a small number of patients
do not get complete relief of symptoms. Currently, there is
increasing interest in the surgical management of GERD.
The goal of surgical therapy is to recreate an antireflux
barrier. Surgical management of GERD focuses on restoring
a physiologic equivalent to the normal LES. It is the only
treatment capable of changing the natural history of GERD.
This interest in surgical therapy has been renewed with the
advent of laparoscopic surgery.
Indications for Surgical Treatment
Currently, there is increasing interest in the surgical
management of GERD. There are a number of reasons for
this. Despite the fact that current medical management is
very effective for the majority, a small number of patients
INTRODUCTION
Gastroesophageal reflux disease (GERD) is defined as the
failure of the antireflux barrier, allowing abnormal reflux
of gastric contents into the esophagus. It is a condition
which develops when the reflux of stomach contents
causes troublesome symptoms and complications. It is a
mechanical disorder which is caused by a defective lower
esophageal sphincter (LES), a gastric-emptying disorder, or
failed esophageal peristalsis. Gastroesophageal reflux is one
of the most common digestive symptoms. Exposure of the
esophageal mucosa to acid, enzymes, and other digestive
secretions leads to acute and chronic inflammations, with
pain, and ulceration or stricture formation if untreated.
Heartburnoccursin5–45%ofadultsinWesterncountries,
depending on the frequency of symptoms, 30–45% suffer
from symptoms once a month and 5–10% everyday. The
majority of patients suffering from GERD experience minor
symptoms for which they do not seek medical attention.
Age does not seem to have an impact on the frequency of
GERD symptoms, and no causal factor has been identified.
Esophagitis due to reflux occurs in approximately 2% of
the global population. It is the most frequent form of lesion
detectedonuppergastrointestinal(GI)endoscopy,occurring
more frequently than gastric ulcersorduodenalulcers.GERD
is often a chronic ailment. After a 5–10-year follow-up, about
two-thirds of patients complain of persistent symptoms
requiring occasional or continuous treatment.
PATHOPHYSIOLOGY
The pathophysiology of GERD is multifactorial, although it is
usually due to the weakening of the anatomical or functional
gastroesophageal barrier located at the esophagogastric
junction. Injury to the esophageal mucosa by acid-peptic
gastric secretions, while secondary to this weakening,
plays a major role in the development of GERD symptoms
and lesions. In fact, suppressing the gastric acid secretion,
which is the usual treatment of this ailment, leads to the
disappearance of symptoms and healing of lesions in almost
all cases. GERD is, therefore, acid-dependent.
Prof. Dr. R. K. Mishra

270 SECTION 2: Laparoscopic General Surgical Procedures
do not get complete relief of symptoms. Secondly, some
patients, particularly those who are in their 20s or 30s,
face the prospect of a lifetime of continuous proton-
pump inhibitor (PPI) therapy with the possible risk of, as
yet, unknown side effects. In addition, the laparoscopic
approach with its benefits of reduced operative trauma and
less time off work has become a more common place. As a
consequence, general practitioners and gastroenterologists
are more convinced to refer patients with disabling
symptoms for surgical treatment. Antireflux surgery is
most often performed to control GI symptoms such as
heartburn and regurgitation that are refractory to medical
therapy. It may also be performed for non-GI symptoms
such as chronic cough, laryngeal disease, and asthma. If
there is solid objective evidence to attribute such symptoms
to reflux. The GI symptoms are also referred to as typical
symptoms and the non-GI symptoms as atypical symptoms.
The gold standard antireflux operation is undoubtedly the
Nissen type of total fundoplication and many studies have
affirmed its effectiveness in controlling acid reflux. However,
new symptoms after fundoplication such as gas bloat and
dysphagia, which probably result from a hypercompetent
LES produced by the Nissen operation, are common.
Concerning the indication for surgery, a distinction
between heartburn and regurgitation symptoms is
considered an important factor (medical treatment appears
to be more effective for heartburn than for regurgitation).
Even after successful medical acid suppression, the patient
can have recurrent symptoms of epigastric pain and
retrosternal pressure as well as food regurgitation due to an
incompetent cardia, insufficient peristalsis, or a large hiatal
hernia.
Surgical therapy should be considered in individuals
with documented GERD who are:
■ Refractory to medical management
■ Associated with hiatus hernia
■ Intolerance to postpartum hemorrhage (PPH) or H2-
receptors
■ Not compliant to medical therapy
■ Have complications of GERD, e.g., Barrett’s esophagus,
stricture, and grade 3 or 4 esophagitis
■ Atypical symptoms such as asthma, hoarseness, cough,
chest pain, and aspiration
Study has shown those patients resistant to antisecretory
treatment are not good candidates for antireflux surgery.
PREOPERATIVE EVALUATION
All the patients should have endoscopy, standard pH
testing, esophageal manometry, and barium esophagram
be performed before antireflux surgery. Nonstandard pH
testing or gastric-emptying study may be required for some
patients.
Upper Gastrointestinal Endoscopy
Esophageal and gastric endoscopy should be performed
to assess the esophageal and gastric mucosa for signs of
malignancypriortoproceedingwithanantirefluxprocedure.
Patients with endoscopic findings of severe (Los Angeles
grade C or D) esophagitis, biopsy-proven Barrett’s esophagus
≥1 cm, or a benign peptic stricture are good candidates for
fundoplication surgery.
Esophageal pH Testing
Esophageal pH monitoring is the gold standard technique
for the detection of gastroesophageal reflux in adults
and children. Patients with typical symptoms of GERD
should undergo standard pH testing. Patients with atypical
symptoms may require nonstandard pH testing, such as
one with dual pH probe or impedance in order to document
proximal and/or nonacidic reflux.
Standard pH Testing
Ambulatory pH testing is the gold standard for diagnosing
pathologic GERD. Prior to antireflux surgery, all patients with
nonerosive GERD, including those with Los Angeles grade
A or B, esophagitis, and those with short-segment (<1 cm)
Barrett’s esophagus, should undergo standard pH testing to
document abnormal distal esophageal acid exposure. An
abnormal pH test in a PPI-dependent patient with typical
symptoms predicts successful outcomes with antireflux
surgery. Standard pH testing can be done via a transnasal
catheter for 24 hours or a wireless pH system for 48 hours
after the patient has been off acid suppression for 7 days.
Multichannel Intraluminal
Impedance Testing
Multichannel intraluminal impedance (MII) is a catheter-
based method to detect intraluminal bolus movement
within the esophagus. MII is performed in combination with
manometry or pH testing. Combined MII and pH (MII-pH)
testing can detect both acid and nonacid gastroesophageal
reflux. It should be recognized that this testing is somewhat
controversial and interpretation is operator-dependent.
Dual pH Probe
Despite other available and seemingly superior technologies
such as impedance testing, the current “gold standard”
diagnosis of extraesophageal reflux continues to be 24-hour
dual pH probe monitoring. This procedure involves placing
a catheter through the nose and into the esophagus. Two
sensors, proximally and distally located within the catheter,
detect the pH level or acidity in the distal esophagus and
hypopharynx. Extraesophageal reflux is diagnosed when
stomach contents are shown to flow upward from the stomach

271
CHAPTER 20: Laparoscopic Fundoplication
Fig. 1: Selection of type of fundoplication.
(GERD: gastroesophageal reflux disease; LES: lower esophageal
sphincter)
to the distal esophagus, and subsequently to the proximal
esophagus and into the hypopharynx. Measurements of pH
are recorded to a small, portable device that is worn on a belt
during the study.
Esophageal Manometry
Esophageal manometry is the most reliable way to assess
LES competence and esophageal peristalsis. Overall, the LES
is incompetent in about 60% of patients with GERD, while
transient relaxation of a competent LES is the cause of GERD
in the remaining 40%. Manometry assesses esophageal
peristalsis as well and occasionally provides alternative
diagnoses, such as scleroderma or achalasia, for which
antireflux surgery may be contraindicated. Manometric
findings may influence the surgical approach such as partial
instead of complete fundoplication for those with weak
peristalsis.
Barium Esophagram
Barium esophagram can demonstrate esophageal length,
presence, and size of any hiatal hernia, presence of any
esophageal diverticulum or stricture, and the extent of reflux
with provocation.
Gastric-emptying Study
A 4-hour gastric-emptying study should be performed when
the history of a patient with GERD symptoms suggests gastric
outlet obstruction or gastroparesis with significant nausea,
repeated vomiting, severe bloating or postprandial fullness,
or retained food in the stomach after overnight fast.
METHODS OF FUNDOPLICATION
There is no one best operation for all patients with GERD.
Currently available antireflux procedures include:
■ Endoscopic radiofrequency treatment (Stretta)
■ Endoscopic transoral incisionless fundoplication (TIF)
■ Laparoscopic magnetic sphincter augmentation (LINX)
■ Laparoscopic Hill gastropexy
■ Laparoscopic partial fundoplication
■ Laparoscopic Nissen fundoplication (NF)
Laparoscopic fundoplication is a safe procedure and
can provide less postoperative morbidity in experienced
hands. Fundus of the stomach, which is on the left of the
esophagus and main portion of the stomach, is wrapped
around the back of the esophagus until it is once again
in front of this structure. The portion of the fundus that
is now on the right side of the esophagus is sutured to
the portion on the left side to keep the wrap in place.
The fundoplication resembles a buttoned shirt collar.
The collar is the fundus wrap and the neck represents the
esophagus imbricated into the wrap. This has the effect of
creating a one-way valve in the esophagus to allow food
to pass into the stomach, but prevent stomach acid from
flowing into the esophagus and thus prevent GERD.
Laparoscopic fundoplication is a useful method for
reducing hospital stay, complications, and early return to
normal activity.
TYPES OF FUNDOPLICATION SURGERY
Laparoscopic fundoplication has become the standard
surgical method of treating GERD. Although Nissen total
fundoplication is the most commonly performed procedure,
partial fundoplication, either anterior or posterior, is
becoming more acceptable because of a suggested lower risk
of long-term side effects (Fig. 1).
The 360° Nissen fundoplication has been the standard
operation for gastroesophageal reflux, but is associated with
substantialratesof“gasbloat,”gagging,anddysphasia(Fig.2).
Toupet fundoplication (TF), a 270° posterior wrap, has
fewer complications, and its outcome in compared with
Nissen fundoplication, is favorable both in children as well
as adults (Fig. 3).
Although Nissen total fundoplication is the most
commonly performed procedure, partial fundoplication,
either anterior or posterior, is becoming more acceptable
because of lower risk of long-term complication. Dor in 1962
described anterior fundoplication as an antireflux operation
for patients who had a Heller myotomy for achalasia. In the
1970s, Watson developed an operation for patient suffering
from GERD.
Most surgeons believe that the TF, a 270° posterior
wrap, originally described in conjunction with myotomy
for achalasia, has fewer complications, and its long-term
outcome in comparison with NF is favorable both in children
as well as adults.
The main tasks of this operation consist of:
■ Preparation of the patient
■ Creation of pneumoperitoneum and insertion of ports
■ Diagnostic laparoscopy and dissection of visceral
peritoneum

Fig. 2: Nissen fundoplication. Fig. 3: Toupet fundoplication (TF), a 270° wrap.
Fig. 4: Laparoscopic fundoplication port position.
■ Mobilization of 5 cm of intra-abdominal esophagus
■ Fundus pull from below the esophagus
■ Insertion of posterior sutures to tighten the crural
opening
■ Fixation of fundus to the left crura
■ Fixation of the fundus with the right crura
■ Fixation of the fundus with esophagus. Inspection of
tightness of fundoplication
■ Irrigation and suction of operating field
■ Final diagnostic laparoscopy for any bowel injury or
hemorrhage
■ Removal of the instrument with complete exit of CO2.
Closure of wound.
PATIENT SELECTION
Many patients have symptoms palliated by lifestyle such as
diet and exercise, others by simple medication, and some
by strong medication such as PPI. A certain proportion
of patients have refractory or long-term symptoms, and
operation can be considered in this group of patients. As
reflux symptoms are frequent and variable, it is wise to
obtain both ambulatory 24 hours pH-metry and esophageal
motility studies prior to surgery. Upper GI endoscopies
should be performed in all patients.
OPERATIVE TECHNIQUE
The original fundoplication as described by Rudolph Nissen
in 1956 involved passage of the gastric fundus behind the
esophagus to encircle the distal 5 cm of the esophagus.
In contemporary surgical practice, fundoplication is
performed laparoscopically in most patients. Compared
with open transabdominal or transthoracic fundoplication,
laparoscopic fundoplication demonstrates comparable
safety, efficacy in symptom relief, and patient satisfaction.
Patient Position
The patient is placed on the operating table with the legs
in stirrups, the knees slightly bent, and the hips flexed
approximately 10°. The operating table is tilted head up by
approximately 15°. Compression bandage is used on leg
during the operation to prevent thromboembolism. The
surgeon stands between the patient’s legs. The first assistant,
whose main task is to position the video camera, sits on the
surgeon’s left side. The instrument trolley is placed on the
patient’s left allowing the scrub nurse to assist with placing
the appropriate instruments in the operating ports.
Television monitors are positioned on either side of the
top end of the operating table at a suitable height for surgeon,
anesthetist, and assistant to see the procedure.
Port Position
The 10-mm camera (port 1) is placed in the midline
approximately 5 cm above the umbilicus; this position will
vary depending on the build of the patient (Fig. 4). After

273
Fig. 5: Port position in fundoplication.
Figs. 6A and B: Alternative port position in laparoscopic fundoplication.
A B
inserting the camera, a 5-mm port (2) is inserted in the right
upper quadrant 8–10 cm from the midline. A port (3), with a
variable5–10mmsize,isplacedintheleftupperquadrant—a
mirror image of the one on the patient’s right.
This allows both 5 mm and 10 mm instruments to be used
through the same cannula without changing ports. A further
5-mm port (4) is positioned in the left anterior axillary line
immediately below the costal margin. This port is mainly
used for a forceps which will hold the tape encircling the
esophagus (Fig. 5). Liver retraction used to be one of the
more problematic aspects of laparoscopic fundoplication. In
our experience, these difficulties have been largely overcome
by the use of the Nathanson liver retractor. Alternate port
position in laparoscopic fundoplication is shown in Figures
6A and B.
Tissue Dissection and Mobilization
Mobilization of Stomach
Thefunduspartofthestomachismobilizednicelyalongwith
the gastroesophageal junction by anteromedial traction. The
short gastric vessels are separated with the help of a bipolar
or harmonic scalpel which aids in further mobilization of the
fundus of the stomach through the earlier formed posterior
window. Care must be taken not to injure the spleen which is
adjacent to the stomach.
Mobilization of Esophagus
Dissection starts at the avascular portion of the lesser
omentum above the hepatic branch of the vagus.
The dissection is continued carefully up to the hiatus, which
canbeseenthroughthedefectcreated.Anopeningiscreated
in the lesser omentum, above the hepatic branch of vagus to
allow better access to the hiatus (Figs. 7A to H).
The right crus is dissected using electrosurgery
and scissors to identify the plane between the crus and
surrounding loose areolar tissues. The loose areolar tissue
around the esophagus is exposed and secures the bleeding
from any blood vessels visible during mobilization of
esophagus. Always remember not to injure the esophageal
wall and vagal fibers when dissecting this area around
esophagus. The space between the hiatus and the anterior
aspect of esophagus is developed using fine dissection by
scissors to divide blood vessels crossing this space.
Lesser Sac Opened
The posterior aspect of the left crus is identified as it meets
the right crus and dissection of its surface commences,
especially the peritoneal covering over the margin of right
crus is dissected down to the fundus from the diaphragm
known as Rossetti dissection technique. Dissection of the
posterior aspect of the left crus is done by lifting the intra-
abdominal esophagus forward with a blunt instrument.
A sling is fed into the jaws of the grasping forceps and then
pulled round behind the esophagus (Fig. 8).

Figs. 7A to H: Mobilization of esophagus.
A
C
E
G
B
D
F
H
Sling is passed through a separate punctured wound
from abdominal wall without port. A grasping forceps is
inserted through one of the port to hold the sling so that the
esophagus can be manipulated. Dissection surroundings
of esophagus in the posterior mediastinum should for
approximately 5–6 cm. Mobilization of the esophagus and
stomach should be sufficient enough to have a good floppy
fundus for wrap (Fig. 9).
The next step is to pull the fundus from behind the
esophagus to form a wrap.

275
Fig. 8: Sling insertion.
Fig. 9: Sling application around esophagus for
proper exposure of crura.
Fig. 10: Mobilized fundus of stomach is pulled from
behind the esophagus.
Fundus Pull
After mobilizing the fundus nicely, the tip of the fundus is
pulled by one of the grasper introduced through below and
right side of the esophagus (Figs. 10 and 11).
The mobilization of stomach should be adequate to give
a floppy fundus for plication otherwise patient may develop
dysphagia. One stay suture may be applied to the fundus to
hold it in place or one of the grasper may be used to keep it
pulled. The next step is crural repair.
Crural Approximation
A posterior crural repair should be performed by
approximating the right and left pillar of the left crus with
sutures.Crurashouldbeapproximatedbehindtheesophagus
using two or three sutures of 2/0 braided polyamide on a
30-mm needle using tumble square knot or surgeon’s knot.
A further one or two sutures are inserted in the same way, at
about 1 cm intervals and tied. It is important not to make the
crural opening too tight since this will produce dysphagia
(Figs. 12A to D).
Further three sutures are then positioned at
approximately 1 cm intervals to the posterior fundus and
the right crus. The sling used for esophageal retraction is
removed. A 50–60 French bougie should be placed in the
stomach along the lesser curvature to calibrate the tightness
of the fundoplication.
Fundoplication
By using an atraumatic grasper in the left hand, the
posterior wall of the fundus is held through the opening
made behind the esophagus. The posterior wall of fundus
is pulled gently and at the same time, the extra-anterior wall
is pushed back to avoid crowding of tissue within the window.
By serial movements of pulling posterior wall forward and
pushing anterior wall back, a sufficient amount of wrap
is made around the esophagus, this can be ascertained
by seeing the “buttock sign.” The wrap made by both
posterior and anterior walls of fundus should not be too
tight. A Floppy Nissen’s is made by doing the “shoe shine”
maneuver. Suture material used is nonabsorbable sutures
such as Dacron, silk, or polypropylene. Approximately
5 cm of mobilized esophagus should be prepared for fundal
wrap.
First suture is taken with full thickness of anterior wall
of fundus, and full thickness of posterior wall of fundus is
taken. Intracorporeal surgeon’s knot are used for plicating
the stomach on to the esophagus, though “tumble square
knots” can also be used.
Two sutures are taken above the first knot at a distance
of1cmbetweeneachknot,involvingfullthicknessofanterior
wall of fundus, partial muscular layer of esophagus, and full
thickness posterior wall of fundus. In the above suture,
wall of esophagus is sandwiched between walls of fundus.
Taking full thickness of esophagus in above sutures should
be avoided as it may cause a complication of perforation of

Figs. 11A and B: Fundus of stomach is pulled from behind the esophagus.
A B
Figs. 12A to D: Approximation of crura.
A B
C D
esophagus. Two sutures are taken below the first knot at a
distance of 1 cm between each knot in similar manner. Most
surgeons would perform a wrap of 2–3 cm (Figs. 13A to C).
Ending of the Operation
Abdomen should be examined for any possible bowel
injury or hemorrhage. The instrument and then port
should be removed carefully. Remove telescope leaving
gasvalveofumbilicalportopentoletoutallthegas.Closethe
wound with suture. Use vicryl for rectus and unabsorbable
intradermal or stapler for skin. Apply adhesive sterile
dressing over the wound.
Patient may be discharged 2 days after operation, if
everything goes well. Long-term observational studies of

277
Figs. 13A to C: Fixation of wrap by intracorporeal sutures.
A B
C
laparoscopic fundoplication performed by experienced
operators generally report that 90–95% of adult patients are
satisfied with the results of their surgery. The patient may
have slight dysphagia initially but usually resolves after 6
weeks. The patient having any complain of dysphagia should
be examined endoscopically after 3–4 weeks of operation.
Dysphagia that persists for >12 weeks requires evaluation,
which typically begins with a barium swallow to assess the
anatomic placement of the fundoplication. In case of tight
plicationendoscopicdilatationtechnique,bougieorguidewire
dilation should be done. Endoscopic dilatation procedure is
well tolerated and produces good results. Patients who have a
360° fundoplication may be candidates for revision to a partial
fundoplication, if dysphagia persists and effective barium
tablet passage cannot be established despite dilation.
Symptoms of gas bloat syndrome can be elicited in
a significant number of patients after fundoplication.
Symptoms tend to lessen over time in most patients. In
patients with severe persistent symptoms despite the
medical treatment approaches, pyloroplasty, pyloric Botox
injection, and pneumatic pyloric dilatation are options in
select patients who have documented gastroparesis.
Long-term mortality of laparoscopic fundoplications
is very low. The reported 30-day surgical mortality rate
of laparoscopic fundoplication is <0.1–0.2%. The most
commonly reported acute complications for laparoscopic
fundoplications are gastric or esophageal injury, splenic
injury or splenectomy, pneumothorax, bleeding,
pneumonia, fever, wound infections, bloating, and
dysphagia. Major acute complications are uncommon.
In a study of 2,655 patients, 4.1% had a complication within
30 days of surgery, including 1.1% infection, 0.9% bleeding,
and 0.9% esophageal perforation.
Rossetti–Nissen Fundoplication
A common modification is a 360° fundic wrap without
division of the short gastric vessels is called Rossetti–Nissen
fundoplication. However, most surgeons prefer to divide
the short gastric vessels to allow for greater freedom of
mobilization and reduced concern about torque on the
fundoplication which is hard to measure and also facilitate
lower esophageal relaxation.
Partial Fundoplications
A partial 270° posterior wrap, TF is used for patients with
severe associated motor abnormalities. A partial 180°
anterior wrap (Dor) has also been described. Based on
currently available data, the choice of anterior versus

Fig. 15: Stretta therapy as a treatment option for gastroesophageal reflux disease (GERD).
Figs. 14A and B: LINX sphincter augmentation system.
A B
posterior or partial versus complete NF should be left to the
individual surgeon.
Hill Gastropexy
The Hill procedure involves imbrication of the anterior
and posterior collar sling muscular fibers at the level of
the gastroesophageal junction around the esophagus with
tethering of the complex to the median arcuate ligament and
closure of the diaphragm. Intraoperative manometry is used
to achieve a desired LES pressure. This operation can also
be used in a patient with a small stomach because of prior
gastric resection. In a randomized trial, laparoscopic Hill
gastropexy and laparoscopic Nissen fundoplication yielded
similar and both excellent outcomes at 1-year follow-up. In
a single-center retrospective study with a median follow-up
of 18.5 years, 85% of patients who underwent Hill gastropexy
reported good to excellent symptomatic outcomes and
quality of life.
Magnetic Sphincter Augmentation (LINX Device)
In 2012, the US Food and Drug Administration (FDA)
approvedtheLINXrefluxmanagementsystemasatreatment
forGERD(Figs.14AandB).Thedeviceworksbyaugmenting
the LES with a ring made up of a series of rare earth magnets.
The magnets have sufficient attraction to increase the LES
closure pressure but permit food passage with swallowing.
Eligible patients must demonstrate typical GERD
symptoms, an abnormal pH study, partial response to
daily PPI therapy, and absence of a large hiatal hernia (>3
cm) or severe esophagitis. Patients who have allergies to
titanium, stainless steel, nickel, or iron should not receive a
LINX prosthesis. Patients who have the LINX device need to
consulttheirsurgeonbeforeundergoingmagneticresonance
imaging (MRI). A new version of LINX considered “MR
Conditional” in a MRI system up to 1.5 Tesla (1.5 T) is now
available. Scanning under different conditions may interfere
with the magnetic strength and function of the device.
Laparoscopic magnetic sphincter augmentation device
has been compared with laparoscopic Nissen fundo-
plication in several meta-analyses. Clinical control of reflux
was comparable after the two procedures in both the short
and longer term. In the longer term, there was less gas
bloat associated with LINX than fundoplication. Presently,
however, there is insufficient evidence that would allow
surgeons to choose between the two procedures.

279
Figs. 16A to E: Transoral incisionless fundoplication (TIF).
A
C D E
B
Figs. 17A and B: EsophyX device for transoral incisionless fundoplication (TIF).
B
A

Stretta Endoscopic Procedure
The Stretta procedure is the most widely studied endoscopic
antireflux procedure. The specialized catheter is placed with
endoscopic assistance over a guidewire. Using monopolar
energy,aseriesof56treatmentsisdeliveredacrossfivelevels.
Stretta is rated as effective therapy in patients with a lower
esophageal pressure of at least 8 mm Hg and hiatal hernia
<3 cm. The energy heats the tissue, ultimately causing it to
swell and stiffen; the way this works was not understood as
of 2019, but it was thought that perhaps the heat causes local
inflammation, collagen deposition, and muscular thickening
of the LES and that it may disrupt the nerves there (Fig. 15).
Transoral Incisionless Fundoplication
Transoral incisionless fundoplication is an endoscopic
procedure performed under general anesthesia to create a
full-thickness serosa-to-serosa plication (Figs. 16A to E).
TIF creates 3–5 cm in length and 200–300° in circumference
partial fundoplication. TIF can be performed in patients
with typical GERD symptoms, no or only low-grade erosive
esophagitis (grades A and B), and no or only small hiatal
hernia (≤2 cm). TIF is contraindicated in patients with high-
grade erosive esophagitis, Barrett’s esophagus, atypical and
extraesophageal symptoms of GERD, scleroderma, or other
esophageal pathology or surgery. The EsophyX device has
been CE marked for the market and FDA approved for the
United States market for TIF procedures (Figs. 17A and B).
Transoralincisionlessfundoplicationhasbeencompared
withPPItherapyinseveralrandomizedtrials.Inthelatesttrial
(TEMPO), 63 patients with GERD refractory to PPI received
TIFversusmaximumstandarddosePPItherapy.At6months,
both regurgitation and extraesophageal symptoms were
eliminated in more TIF than PPI patients (62 vs. 5%); 90% of
TIF patients were off PPIs. After 6 months, all patients in the
PPI (control) group elected to cross-over to TIF. At 3 years,
90% and 88% of patients reported elimination of troublesome
regurgitation and all atypical symptoms, respectively.
Although TIF is associated with fewer postoperative adverse
effects such as gas bloating and dysphagia compared with
surgical fundoplication, the durability of TIF is less certain
than that of surgery.
For most patients undergoing surgical treatment
for GERD, laparoscopic NF is a better option. This
procedure appears to be the most effective and durable
amongst all the procedures but is also associated
with the greatest potential for dysphagia, difficulty in
vomiting, and gas bloating. Patients with decreased
esophageal motility or morbid obesity may benefit from an
alternative procedure. For an individual patient, the best
procedure may be the procedure in which the surgeon is
most skilled.
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