Fundoplication

Fundoplication is a surgical procedure designed to strengthen the natural barrier against gastro-oesophageal reflux. It may be considered for carefully selected patients where reflux is well established and a specialist assessment indicates that the procedure is likely to provide significant clinical benefit.

What is fundoplication?

Between the oesophagus and the stomach there is an anatomical and functional barrier that prevents gastric contents from rising. This mechanism involves the lower oesophageal sphincter, the diaphragm and the position of the gastro-oesophageal junction.

When this barrier becomes ineffective, stomach contents can rise into the oesophagus and cause symptoms such as heartburn or regurgitation. A hiatal hernia, in which part of the stomach protrudes through the opening in the diaphragm, can contribute to disrupting this mechanism.

Fundoplication aims to reconstruct and reinforce this barrier. To do this, the surgeon mobilises the fundus – the upper part of the stomach – and wraps it around the lower section of the oesophagus to form a sleeve.

The aim is to reduce reflux whilst maintaining an adequate passage for food and preventing unnecessary resistance to swallowing or the release of air from the stomach.

Complete and partial fundoplication

The sleeve may encircle the oesophagus completely or only partially. This difference gives rise to different surgical techniques.

In Nissen fundoplication, the fundus completely surrounds the lower part of the oesophagus. In Toupet fundoplication, the wrap is partial and posterior. The Dor technique involves a partial anterior fundoplication and is usually used in more specific contexts, often in conjunction with other procedures on the oesophagus.

The choice does not depend on a single technique that is universally suitable for all cases. The aim is to strike a balance between controlling reflux and preserving comfortable swallowing and the ability to expel air from the stomach.

Indications

Fundoplication may be considered when there is sufficiently documented gastro-oesophageal reflux disease and clinical assessment indicates that intervention on the anti-reflux barrier may offer significant benefit.

One of the most common indications is the persistence of typical symptoms, particularly regurgitation, despite appropriately indicated treatment. It may also be considered in cases of intolerance to certain pharmacological treatments, a clinically significant hiatal hernia or severe oesophagitis.

In some people who achieve good control with proton pump inhibitors, surgery may be considered as a long-term alternative after jointly assessing the benefits, limitations and possible subsequent functional effects.

The relationship between symptoms and reflux takes on particular importance when symptoms such as chest pain, cough, hoarseness, throat clearing or pharyngeal discomfort predominate. These symptoms may have different causes, and their response to anti-reflux surgery is less predictable if the involvement of reflux is not adequately demonstrated.

Barrett’s oesophagus alone does not determine the need for fundoplication. Where there is an independent indication for antireflux surgery, it may form part of the treatment, but surgery does not replace the necessary endoscopic monitoring.

Pre-operative assessment and choice of treatment

The assessment prior to a fundoplication aims to answer three main questions: whether there is clinically significant reflux, what the anatomy of the junction between the oesophagus and the stomach is like, and how the oesophagus moves during swallowing.

The information obtained helps to confirm the indication, select the most appropriate technique and identify situations that may require alternative treatment.

Upper gastrointestinal endoscopy

Endoscopy allows direct visualisation of the oesophagus and stomach, identification of any oesophagitis, assessment of the presence and characteristics of a hiatal hernia, and the ruling out of other lesions that might explain the symptoms.

An endoscopy showing no visible lesions is interpreted alongside the rest of the clinical and functional information, as the assessment of reflux may require further tests.

Reflux monitoring

When it is necessary to objectively measure how much gastric content rises into the oesophagus, pH monitoring or pH-impedance monitoring may be used.

These tests record episodes of reflux over a specific period and allow the temporal relationship with symptoms to be studied.

Oesophageal manometry

Oesophageal manometry assesses the contractions that propel food into the stomach and the function of the oesophageal sphincters.

Prior to anti-reflux surgery, it is particularly useful for assessing oesophageal motor function and detecting significant disorders, such as achalasia, which can produce similar symptoms but require a different therapeutic approach.

The range of tests is tailored to what is already known about the patient’s case. Not everyone requires exactly the same diagnostic sequence.

Procedure

Fundoplication is carried out under general anaesthesia. The usual approach is minimally invasive, generally via laparoscopy, using small incisions through which a camera and surgical instruments are inserted.

Some procedures may be carried out using robot-assisted surgery. The choice of approach depends on the characteristics of the case, the surgical plan and the team’s experience.

Where a hiatal hernia is present, one of the first steps is to return the stomach to its abdominal position and reconstruct the opening in the diaphragm around the oesophagus.

The gastric fundus is then mobilised and a fundoplication is constructed around the lower part of the oesophagus. The sleeve is carefully adjusted to reinforce the anti-reflux mechanism without creating excessive resistance to the passage of food.

The extent of the fundoplication — whether complete or partial — is determined based on the patient’s anatomy, the results of the functional study, the characteristics of the hernia (if present) and the surgeon’s judgement.

The duration of the procedure and the length of hospital stay may vary depending on the anatomy, the complexity of the repair, previous abdominal operations and the immediate post-operative course.

Recovery and diet

During the first few days, you may experience some discomfort at the small incisions, a feeling of tightness in the abdomen, or pain radiating to the shoulder associated with the laparoscopy.

It is also common to notice that food passes through the system more slowly. The area where the operation was carried out is initially swollen and requires a period of adjustment. This temporary difficulty in swallowing, known as dysphagia, usually improves gradually.

Food is reintroduced gradually. In the early stages, liquids or soft-textured foods may be recommended, moving on to more solid foods later, depending on how well you tolerate them and the advice given.

Eating slowly, taking small portions and chewing thoroughly helps with this adjustment. Dry, very hard, fibrous or gas-producing foods may be more difficult to eat during the early stages.

The pace of recovery does not necessarily follow the same timeline for everyone. It depends on the surgical technique used, any hernia repair that may have been required, and the individual’s progress.

A return to work, exercise and other activities is also gradual and depends on the type of physical exertion and your recovery following the operation.

Abdominal bloating and difficulty burping

After the gastro-oesophageal junction has been reinforced, it may be more difficult to expel the air accumulated in the stomach by burping.

Some people experience abdominal bloating, a feeling of fullness or increased gas build-up. The ability to vomit may also be reduced.

These effects may improve during recovery, although in some people they persist to varying degrees. For this reason, they form part of the information that should be taken into account before choosing a surgical technique.

Benefits and outcomes

In appropriately selected patients, fundoplication can provide long-term control of regurgitation and other typical symptoms associated with reflux, as well as reducing the oesophagus’s exposure to gastric contents.

The procedure may also reduce the need for drug treatment. Some people no longer require proton pump inhibitors, whilst others continue to use them occasionally or on a long-term basis, depending on their clinical course.

The response is less predictable when cough, hoarseness, throat discomfort or other extra-oesophageal symptoms predominate. In these cases, demonstrating the involvement of reflux beforehand helps to establish more realistic expectations.

The aim of surgery is to achieve clinically significant and potentially long-lasting control of reflux. The subsequent course may vary depending on anatomy, the type of symptoms and other individual factors.

Risks and potential long-term effects

Like any abdominal procedure, fundoplication may be associated with bleeding, infection, injury to neighbouring structures, or complications relating to anaesthesia and the laparoscopic approach.

In addition to these general surgical risks, there are effects specifically related to the functional change occurring at the junction between the oesophagus and the stomach.

Dysphagia is common in the early stages of recovery. If it persists, gradually worsens or makes it difficult to eat properly, further tests may be necessary and, in certain situations, endoscopic dilation or other treatment may be required.

Abdominal distension, a feeling of fullness and difficulty burping or vomiting are other possible functional effects. Over time, the fundoplication may shift, become too tight or lose some of its effectiveness. Once a hiatal hernia has been repaired, a recurrence of the hernia may also occur.

Revision surgery is possible where there is a significant anatomical or functional abnormality, although it usually requires particularly careful assessment due to its greater technical complexity.

Recurrence of reflux and follow-up

Following fundoplication, follow-up allows for the assessment of symptom progression, adaptation to diet and the function of the anti-reflux repair.

Reflux or certain digestive symptoms may recur over time. Possible causes include a new hiatal hernia, changes in the position or configuration of the fundoplication, significant weight fluctuations or other anatomical changes.

When heartburn, regurgitation, chest pain or other persistent discomfort reoccur, the next step is to determine their cause. Depending on the case, it may be necessary to perform a further endoscopy, monitor reflux or repeat functional tests.

This re-evaluation allows a distinction to be made between a genuine recurrence of reflux and symptoms related to other mechanisms, and helps determine whether medical treatment, follow-up, endoscopic treatment or a further surgical assessment is required.

Treatment options

Fundoplication is one of the various options available for treating gastro-oesophageal reflux disease.

For many people, medical treatment combined with measures relating to diet, weight and certain lifestyle habits provides adequate control of symptoms.

When considering an interventional treatment, there may be other alternatives for specific patient profiles. These include magnetic oesophageal sphincter augmentation, which uses an implantable device placed around the gastro-oesophageal junction, and certain endoscopic treatments such as incisionless transoral fundoplication.

These strategies have their own indications, limitations, risks and levels of evidence, and are not simply equivalent or more modern versions of the same procedure.

Obesity can significantly alter the therapeutic strategy. In some people, it may be more appropriate to consider a procedure that addresses both excess weight and reflux simultaneously, rather than performing a conventional fundoplication.

The choice depends on the diagnosis, anatomy, associated conditions and informed preferences.

Situations requiring a specific assessment

Respiratory or throat symptoms

Where coughing, hoarseness, throat clearing or other discomforts outside the oesophagus predominate, the assessment must take particular care to establish whether there is a genuine link to reflux. The response to surgery is less predictable when these symptoms are associated with other underlying causes.

Barrett’s oesophagus

The presence of Barrett’s oesophagus forms part of the gastrointestinal assessment and endoscopic follow-up. Fundoplication may be considered where there is an anti-reflux indication, but the procedure does not replace the specific monitoring required for Barrett’s oesophagus.

Hiatus hernia

Where a hiatal hernia is present, its anatomy and size influence the planning of the procedure. Repair of the hiatus is usually carried out as part of the same operation before the fundoplication is performed.

Oesophageal motility disorders

The oesophagus’s ability to propel food is assessed prior to surgery using functional tests where indicated. This information may influence the choice between a complete or partial fundoplication and helps to identify disorders requiring alternative treatment.

Obesity

Significant excess weight can influence both reflux and the choice of surgical treatment. In certain cases, the team may consider alternatives that allow both problems to be addressed simultaneously.

Signs requiring medical assessment

During recovery, you should contact the healthcare team if you experience difficulty swallowing that progressively worsens, prevents you from drinking, or does not improve as expected. Repeated vomiting, fever, increasing abdominal pain, redness or discharge from wounds, and severe bloating associated with an inability to tolerate food also require assessment.

The persistent recurrence of regurgitation, heartburn or chest pain after recovery may also warrant a further assessment to determine the cause.

Significant breathing difficulties, severe chest pain, loss of consciousness, bleeding or a rapid deterioration in general condition require urgent medical attention.

Specialists involved

The clinical pathway leading to fundoplication usually begins with confirmation that the symptoms are indeed due to gastro-oesophageal reflux and with an assessment of the anatomy and function of the oesophagus.

The Gastroenterology department is involved in this initial phase, integrating the symptoms, endoscopy and functional tests required to establish the diagnosis and assess the need for an anti-reflux strategy. At the Publio Cordón Memorial Hospital, there are gastroenterology specialists who specialise specifically in gastro-oesophageal reflux disease and its complications.

The Digestive Endoscopy Unit can contribute to the preliminary assessment through gastroscopy and in the evaluation of the oesophageal mucosa, oesophagitis, hiatal hernia and other relevant conditions. The unit itself has specialists dedicated specifically to gastro-oesophageal reflux disease.

When the assessment confirms that surgery may be beneficial, the General and Digestive Surgery Department evaluates the anatomy, the surgical indication and the most appropriate technique. The Memorial’s department organises its surgical activity into specialist areas, including oesophagogastric surgery, and incorporates advanced laparoscopic and robotic surgery where indicated.

This coordination between Gastroenterology and Surgery is particularly important in fundoplication: functional and endoscopic tests help to confirm the cause of the symptoms, whilst the surgical assessment determines how to reconstruct the anti-reflux barrier and which type of fundoplication is best suited to each individual case.

Anaesthetology and Intensive Care are involved in the perioperative assessment and in administering general anaesthesia during the operation.

Nutrition and Nursing may be involved during recovery to guide the gradual reintroduction of food and post-operative care. Where there are respiratory symptoms, voice changes or other manifestations requiring further investigation, the care pathway may incorporate other specialities on a case-by-case basis.

Not everyone requires exactly the same tests or the involvement of all these professionals. The care pathway is tailored to the type of symptoms, the available tests, the anatomy of the gastro-oesophageal junction and the expected response to surgery.

Medical information for general guidance

This information sheet aims to help you understand what fundoplication involves, when it may be considered as a treatment for gastro-oesophageal reflux, which tests are used to assess whether it is appropriate, how the surgery is performed, and what changes may occur during recovery. It also explains the main techniques, their potential benefits, risks and alternatives.

At the Publio Cordón Memorial Hospital, we believe it is important for medical information to be accurate, understandable and useful in guiding each person through their care journey. Our specialists devote part of their work to explaining conditions, tests and treatment options in an accessible way, helping patients and their families to better understand each stage and to participate with greater confidence in decisions about their health. This commitment to knowledge and public outreach is also part of our dedication to research and medical progress.

The information contained in this fact sheet describes the general principles of fundoplication. The indication for the procedure and the choice of technique must be tailored to the individual, taking into account the relationship between symptoms and reflux, anatomy, oesophageal function, the presence of a hiatal hernia, associated conditions and the available alternatives.