Dor vs Nissen Fundoplication for Heartburn Treatment

Dor vs Nissen Fundoplication for Heartburn Treatment

Johane from Houston, TX sent us this question: “I had a 270-degree Dor fundoplication in January 2020 with paraoesophageal hernia repair. I did not have a myotomy. I understand that the Dor is rarely performed today and usually only with a myotomy.

Seven months later, my fundoplication has slipped, and my hernia has returned although currently not as large as before. It does not seem to have ever controlled my acid reflux and I have Los Angeles Stage D damage to much of my esophagus. My PH score is 84.

Your article says that Dor fundoplication is rarely performed today. I’ve searched and searched and cannot find many references to a Dor without also mentioning myotomy. My surgeon insists that it isn’t true that Dor is not common today. After reading up on it, I do not understand why she chose this technique for someone who wasn’t having a myotomy.

In addition, I suspect I have vagus nerve damage from the fundoplication. I have breathing problems, an IBS-like digestive disorder, food intolerances, what seems like vastly increased stomach acid, and tingling in my feet and legs on a daily basis. I never had any of these symptoms before having a Dor fundoplication. Is it possible that Dor is more likely to cause damage to the vagus nerve? Please comment — thanks!”

Dear Johane,

Dor fundoplication is rarely performed in Houston for treatment of acid reflux disease. The most commonly performed is Nissen fundoplication or 360-degree wrap. Nissen fundoplication is a reliably and effective procedure when properly performed. The gastric fundus that is used to wrap around the esophagus is a posterior structure. Therefore, it is much easier to swing the fundus posterior to esophagus to perform a loose and floppy Nisse fundoplication. On the other hand, during a Dor fundoplication, your acid reflux surgeon rotates the gastric fundus from lateral to medial anterior to esophagus to create a partial wrap. Dor fundoplication is most commonly performed in the setting of Heller myotomy as you mentioned. It is believed that the fundoplication protects the newly myotomized esophagus. I personally prefer a Toupet fundoplication in this setting for the same reason I mentioned previously: gastric fundus is anatomically located posterior to esophagus. A posterior wrap makes more sense to me to perform.

Vagal nerve injury is not higher with Dor fundoplication. Slippage and recurrent hiatal hernia are not higher with Dor fundoplication. Both complications are minimized by meticulous surgical technique, comprehensive acid reflux work up and patient selection. I strongly recommend you consult with an acid reflux specialist to evaluate your symptoms and check the anatomy of your current fundoplication. A treatment tailored to your condition will help you stop acid reflux and improve your quality of life.