A further modification of fundoplication: 90° Anterior fundoplication

Background: Laparoscopic Nissen fundoplication is the most widely applied procedure for the surgical treatment of gastroesophageal reflux. However, it can be followed by adverse outcomes, including dysphagia and "wind-related" problems. To reduce the likelihood of side effects, we have progressively modified this procedure to an anterior 90° partial fundoplication. Methods: The procedure entails posterior hiatal repair, posterior esophagopexy, accentuation of the angle of His, and construction of a 90° anterior partial fundoplication. Clinical follow-up was performed prospectively using a standardized questionnaire. Results: From February 1999 to June 2001, 83 patients underwent 90° anterior fundoplication for gastroesophageal reflux disease. In 45 the procedure was chosen because of specific patient or surgeon preference, and in 38 it was performed within the context of an ongoing randomized trial. Operating time ranged from 20 to 140 minutes (median, 52 min), and all but one of the procedures were completed laparoscopically. One patient experienced a major postoperative complication-small bowel injury from Veress needle. Follow-up extends up to 2 years (median, 1 year). Two patients have undergone further surgery, both for recurrent reflux. Control of reflux has been acceptable, with a reduction in heartburn symptom scores and high overall satisfaction. Postoperative dysphagia measured using a visual analog scale was less following surgery compared with preoperative scores. Eighty-two percent of patients could belch normally 3 and 12 months after surgery. Conclusions: Ninety-degree anterior fundoplication achieves good control of reflux and a low incidence of side effects. To further evaluate its potential, we are currently undertaking a prospective randomized trial.