Anterior Partial Fundoplication

For more than five decades, the gold standard operation for gastro-esophageal reflux disease has been Nissen fundoplication. However, in some patients wrapping the gastric fundus fully around the esophagus is followed by troublesome new symptoms such as abdominal bloating, dysphagia, inability to belch and flatulence, and these problems are probably generated by an over-competent valve which results following Nissen fundoplication. To reduce the risk of these side effects, surgeons have evaluated various modifications to the Nissen procedure, including partial fundoplications in which the gastric fundus is wrapped only part way around the distal esophagus, thereby generating a more physiological gastro-esophageal valve mechanism. A partial fundoplication can be constructed using either an anterior or a posterior approach, with the lowest risk of side effects following anterior partial fundoplication variants. Long-term follow-up from randomized controlled trials demonstrate that anterior partial fundoplications are followed by a reduced risk of side effects, and the overall success rate, defined using measures of overall satisfaction with the surgical outcome, is at least as good as following Nissen fundoplication. However, there are trade-offs between the risks of recurrent reflux vs. side effects, and these balance somewhat, with differences in these risks correlating with the extent of the fundoplication constructed. This chapter describes the indications, critical technical aspects pertinent to the creation of a satisfactory anterior partial fundoplication, and outcomes.