Choosing a Partial or a Total Fundoplication

The surgical literature is replete with articles debating the pros and cons of the Nissen fundoplication. Advocates of partial fundo-plications such as the Toupet and Belsey fundoplication point out advantages of less dys-phagia and preservation of the ability to vomit. Proponents of the Nissen fundoplication claim superior control of acid reflux as well as ease of performance of the procedure. In fact, there is little level 1 evidence to support the superiority of one procedure over another when performing a redo fundoplication. The choice of fundo-plication should be tailored to the symptom or anatomic defect needing correction. Patients who had a good short-term result from a Nissen fundoplication should probably have a full wrap reconstructed. Those patients who had a partial fundoplication with poor control of acid reflux should be considered for conversion to a Nissen. If a clear technical error can be identified that caused a full fundoplication to fail, one should not hesitate to reconstruct the 360° fundoplication in a proper manner. However, it is logical to perform partial fundoplications on patients that have had a prior Nissen fundoplication and complain of persistent dysphagia or gas bloat syndrome. Patients who undergo reoperation to correct wrap herniation may benefit from a procedure that anchors the fundus to the hiatus such as a Hill repair, Belsey procedure, or Toupet procedure. When an esophageal lengthening procedure is performed, a partial fundoplica-tion has theoretical advantages because the gastric tube that becomes the distal neoesopha-gus is aperistaltic.

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