Fundoplication: Old Concept for Novel Challenges?

Background: Gastroesophageal reflux disease (GERD), the most common esophageal disorder worldwide, is a progressive condition that may lead to Barrett's esophagus and adenocarcinoma. Upfront therapy with proton pump inhibitors is ineffective in up to 40% of patients. The scope of surgical therapy is to reconstruct the natural antireflux barrier provided by the diaphragmatic crura, the lower esophageal sphincter, and the gastroesophageal flap valve. Summary: For 70 years, the 360° Nissen fundoplication has dominated the surgical scenario and is still considered the gold-standard treatment. However, over the past two decades, the Toupet and Dor partial fundoplications have emerged as alternative options to decrease the incidence of dysphagia and gas-bloat syndrome. Randomized and observational clinical studies have shown that the outcomes of partial fundoplication compare favorably with those of the Nissen and can provide satisfactory quality of life minimizing the risk of side effects. However, reflux control and anatomical integrity of partial fundoplications may fade away over time. Further research and close scrutiny of new surgical procedures and technologies is in progress to improve clinical outcomes and provide a more personalized and durable antireflux therapy. Key Messages: Laparoscopic antireflux surgery is a safe and effective therapy for GERD. It should be performed in centers offering a comprehensive diagnostic pathway and a spectrum of techniques tailored to the individual GERD phenotype.