Rick from Houston sent us this question: My acid reflux doctor gave me the option of partial, 270 degree also known as Toupet fundoplication or complete, 360 degree wrap, also known as Nissen fundoplication. My doctor explained that Nissen fundoplication is sometimes a little difficult with certain foods to go down, but the Toupet fundoplication may allow some acid reflux to occur. What do you recommend?
Dear Rick,
Thank you for your question. Both 270 and 360 degree wraps or Toupet and Nissen fundoplication procedures are equally effective in treating acid reflux and eliminating GERD related symptoms. The key to Toupet or Nissen fundoplication reliability and effectiveness is good surgical technique. Both surgeries have to be flawlessly performed to restore the acid reflux barrier and achieve excellent outcome.
At Houston Heartburn and Reflux Center, we mostly perform Nissen fundoplication and our post-operative dysphagia rate is less than 1%. Dysphagia means difficulty swallowing food. A short and floppy 360 degree wrap, when properly performed, is associated with a very low dysphagia rate. We reserve Toupet fundoplication for severe esophageal dysmotility including cases like achalasia detected on pre-operative esophageal manometry study. Scleroderma patients and patients with years of poorly controlled acid reflux disease have poor esophageal contractions and are better served with a Toupet rather than Nissen fundoplication. Again, both 270 and 360 degree have the same efficacy in terms of controlling acid reflux. In rare situations, a small gastric fundus can sometimes prevent us from performing a floppy 360 degree wrap and in this case, a partial 270 degree wrap is indicated.
By the same token, patients with a large gastric fundus don’t do well with a partial wrap. A 270 degree wrap is a floppy and redundant posterior gastric fundus may not control acid reflux as expected. In this particular situation, we prefer to offer a two stitch (as opposed to the traditional 3 stitch) Nissen fundoplication. Such approach allows for better acid reflux control as it offers the patient a more suitable anti-reflux barrier with a very low dysphagia rate.
The take home message is summarized by the following: Not all acid reflux patients are created equal. An expert acid reflux specialist will tailor the fundoplication to the particular patient situation to achieve best possible outcome.