Overview of Antireflux Surgery
The most common antireflux surgery is known as a fundoplication (fundo means top of stomach and plication means to fold). Fundoplication procedures involve wrapping the upper portion of the stomach around the end of the esophagus and stitching it in place. This technique reinforces the antireflux barrier and the junction between the esophagus and the stomach. Traditional surgery has been performed for over 50 years and has proven successful at treating GERD symptoms.
By mechanically reconstructing the antireflux barrier, the technique aims to naturally eliminate reflux by restoring the body’s normal defense.
When to Consider Antireflux Surgery
Most people with mild GERD can successfully control symptoms through dietary and lifestyle changes. Sometimes people begin using over the counter and/or prescribed medicines. For patients who experience inadequate relief and/or side effects from medication, surgical intervention may be appropriate.
In addition, surgery may be suitable for patients who have any of the following:
- concerns about the long-term side effects or costs associated with medication
- certain complications of GERD (e.g. Barrett’s esophagus, narrowing of the inside space of the esophagus)
- symptoms of GERD outside the esophagus (e.g. asthma, hoarseness, cough, chest pain, aspiration)
Goals of Antireflux Surgery [1-4]
The goal of a fundoplication is to restore the normal functions of the junction between the esophagus and the stomach. This is accomplished by wrapping the upper portion of the stomach (the fundus) around the esophagus either partially or totally. The specific goals of the surgery are:
- Reduction of a hiatal hernia (if present) by repairing the enlarged opening of the diaphragm and ensuring that the stomach and esophagus are properly positioned below the diaphragm
- Restoration of the angle at which the esophagus enters the stomach
- Increase in the pressure of the muscle that controls the valve between the stomach and the esophasgus; this recreates a one-way valve to prevent reflux
Types of Antireflux Surgery
Although fundoplication was first performed as open surgery, technological advances in the 1990s enabled a laparoscopic approach. A laparoscopic procedure involves accessing the abdomen via several small incisions. The patient is sedated for the procedure. The surgeon repairs any hiatal hernia before performing the fundoplication. Laparoscopic fundoplication can be performed on patients with any size hiatal hernia. Patients typically return to work within 1-2 weeks.
The so-called gold standard for antireflux surgery has been the laparoscopic Nissen procedure, a total fundoplication which wraps the fundus 360 degrees around the esophagus and results in a hyper functioning antireflux valve. Because the esophagus and the stomach are modified beyond normal anatomy, natural bodily functions such as belching and vomiting may be limited.
Some surgeons can also perform a partial fundoplication (i.e., a less than 360-degree wrap) which more closely mimics normal anatomy. However, this type of procedure can require more surgical precision and is not as common.
In a randomized study, 92% of patients who had laparoscopic Nissen fundoplications reported symptom control five years after the surgery. 
However, it is important to remember that laparoscopic fundoplication is a surgical procedure with inherent associated risks including bleeding, infection, and injury to internal organs.
An incisionless approach is available for patients with smaller hiatal hernias. Since it is a fundoplication, the Transoral Incisionless Fundoplication (TIF) procedure treats the underlying cause of GERD. It has an excellent safety profile, with fewer side effects than conventional antireflux surgery. The TIF procedure is performed through the mouth with no abdominal incisions. Patients typically return to work in less than one week.
Associated complications are typically milder than for laparoscopic procedures, e.g. sore throat or difficulty swallowing. Any complications usually resolve within a few weeks of surgery.
 Jobe, B.A., et. al. Endoscopic Appraisal of the Gastroesophageal Valve After Antireflux Surgery. Am J of Gastro 2004.
 Nissen R, The Treatment of Hiatal Hernia and Esophageal Reflux by Fundoplication. Hernia 1964;30:488-496.
 Adler, R.H., et. al. A valve mechanism to prevent gastroesophageal reflux and esophagitis. Surgery 1958;44:63-75.
 Little, A., et. al. Mechanisms of Action of Antireflux Surgery: Theory and Fact. World J of Surg. 1992;16:320-5.
 Galmiche JP, et. al.; LOTUS Trial Collaborators. JAMA. 2011 May 18;305(19):1969-77. Laparoscopic antireflux surgery vs esomeprazole treatment for chronic GERD: the LOTUS randomized clinical trial. JAMA. 2011 May 18;305(19):1969-77.