The History of Nissen Fundoplication: What Can We Learn?

The 360-degree fundoplication or Nissen fundoplication, the most reliable treatment for GERD, is named after Dr. Rudolf Nissen. A German surgeon with great power of observation and astute judgment. In 1936, he treated an advanced case of acid reflux disease in a 28-year-old man with a distal esophageal ulcer penetrating into the pericardium. Nissen resected the gastroesophageal junction and anastomosed the remaining esophagus to the gastric fundus. He then wrapped the newly formed anastomosis with surrounding gastric fundus wall in an effort to prevent leakage. The patient did well and Nissen noted in follow-up that the patient’s acid reflux symptoms have resolved.

During that period, the main treatment of acid reflux disease consisted of hiatal hernia repair. Hiatal hernia repair by itself has been associated with high failure rate. Still, Nissen did not attempt to duplicate his initial success with fundoplication till 1955. In that year, he operated on a 49-year-old acid reflux patient without hiatal hernia. He took down the phrenoesophageal membrane and mobilized the distal esophagus. He then passed the gastric fundus through the retro-esophageal space without dividing the short gastric blood vessels. He placed around 5 interrupted sutures around the distal 6 cm of the esophagus to create a long fundoplication in nowadays standards. He made sure to perform the fundoplication around a large boogie to prevent narrowing. Patient did well and Dr. Nissen reproduced his results in subsequent cases.

Over the past 60 years, the Nissen fundoplication has been perfected to become the safest, most effective treatment of GERD. The fundoplication is now laparoscopically performed through tiny incisions allowing for fast recovery and minimal pain. The short gastric blood vessels are divided and the gastric fundus is completely mobilized. A loose fundoplication is created and its length is limited to less than 2.5 cm to prevent postoperative dysphagia. To this day, the exact mechanism of action of a 360 or 270-degree fundoplication remains unknown. The mechanical reinforcement of the lower esophageal sphincter is a naïve assumption of the fundoplication mechanism of action. GERD is a multifactorial disease and in my opinion GERD is an esophago-gastric and sometimes an esophago-gastro-duodenal motility disorder like gastroparesis. Gastric fundus “relocation” whether in the form of a Toupet, Nissen or Dor fundoplication alters certain motility patterns resulting in the elimination of retrograde gastric content flow into the esophagus. To develop newer anti-reflux therapies, our thinking must evolve beyond the futile attempts of lower esophageal sphincter reinforcement using bands and magnets. A more rational target for GERD treatment appears to be the gastric fundus as it has been for the past 60 years. Gastric motility patterns in health and disease remain not fully elucidated. Research in this field is needed to improve our understanding of GERD and other diseases like gastroparesis, obesity and diabetes.