Does Nissen Fundoplication Length Impact Outcomes?

Jeremy P Parcells, MD, Anton Simorov, MD, Matthew R Goede, MD, Ajay N Ranade, MD, Vishal M Kothari, MD, Dmitry Oleynikov, MD

University of Nebraska Medical Center

Introduction:
The goal of antireflux surgery has been to provide an operation that has as much protection against reflux as possible while causing a minimal amount of dysphagia. In order to accomplish this, previous studies have advocated that a Nissen fundoplication should be both loose and two centimeters in length. However, we believe that a shorter Nissen will cause less dysphagia while offering an excellent antireflux procedure.

Methods:
248 consecutive patients at a single institution, over a ten year period from February 2002 to March 2012 underwent laparoscopic Nissen fundoplication and were entered into a prospective database. Preoperative data including symptom scores, pH studies, manometry, and upper gastrointestinal studies were obtained and postoperative data included symptom scores and upper GI. Nissen fundoplication was performed and inspected with endoscopy at the end of each case. Fundoplication was initially performed at a length of 2 cm, however over time that length was initially shortened to 1.5 cm and finally to 1 cm.

Results:
A total of 40 patients received a 2 cm wrap with 38 available for long-term follow-up; a total of 162 patients received a 1.5 cm wrap with 136 available for long-term follow-up; a total of 46 patients received a 1 cm wrap with 44 available for long-term follow-up. Mean follow-up was ten months. In the 2 cm fundoplication patients, 9 reported symptoms of reflux (23.7%) and 7 reported symptoms of dysphagia (18.4%). In the 1.5 cm fundoplication patients, 22 reported symptoms of reflux (16.2%) and 38 reported symptoms of dysphagia (27.9%). In the 1 cm fundoplication patients, 8 reported symptoms of reflux (18.2%) and 5 reported symptoms of dysphagia (11.4%). In comparison to a 2 cm fundoplication, a 1.5 cm fundoplication showed no statistically significant difference in reflux (p=0.34) or dysphagia (p=.30). In comparison to a 2 cm fundoplication, a 1 cm fundoplication showed no statistically significant difference in reflux (p=0.59) or dysphagia (p=.53).

Conclusion:
In comparison to a standard 2 cm short, floppy Nissen fundoplication, a 1.5 cm or 1 cm Nissen fundoplication showed no statistically significant difference in terms of postoperative symptomatic reflux or dysphagia. There is a trend, although not statistically significant, to suggest that an ultra-short 1 cm Nissen fundoplication may cause less long-term dysphagia while still providing equivalent protection against reflux.


Session: Poster Presentation

Program Number: P249

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