Fundoplication and the Short Gastric Vessels: Divide and Conquer

Dr. O’Boyle and associates have published 5-year follow-up data from their prospective randomized trial of laparoscopic Nissen fundoplications performed with and without division of the short gastric vessels. ¹ Early results of this trial, which suggested no difference between the two groups other than an increased operating time in those undergoing division of the short gastrics, were published in this journal in 1997. ² In this update, they have obtained clinical outcome measurements by telephone interview. At prolonged follow-up there was no difference between the two groups in the incidence of upper GI symptoms, heartburn, or dysphagia. There was an increased incidence of excess flatus and a “decreased incidence of ability to relieve bloating” in patients who underwent division of the short gastric vessels. Their conclusions are that division of the short gastric blood vessels during laparoscopic Nissen fundoplication does not improve clinical outcome over long-term follow-up. These results mirror those of two other series of Nissen fundoplications from Scandinavia in patients undergoing either laparoscopic ³ or open ⁴ fundoplication in randomized trials. In each of these studies, division of the short gastric vessels conferred no benefit, whereas operative time was significantly increased.

Given the similar results of these prospective randomized trials, surgeons will undoubtedly conclude that division of the short gastric vessels is not necessary for the safe and effective performance of a “Nissen” fundoplication. However, it is important to read between the lines. In matters of surgical technique, eponymous procedures (i.e. Nissen, Whipple, etc.) may have numerous technical variations and the precise technique must be specified. Furthermore, in an operation such as a fundoplication, which is a functional rather than ablative procedure, the technical details may be of even greater importance to optimize postoperative clinical outcome. When performing a randomized trial of surgical technique, the surgeon cannot be ‘blinded‘ and the results are necessarily biased towards the technique most familiar to the surgeon. In evaluating the fundoplication technique of O’Boyle et al., the short gastric vessels were divided in half of the patients, but the fundus was not fully mobilized – “the posterior attachments of the fundus were divided only when needed to achieve adequate fundal mobilization.” In these patients, the apex of the fundus was used to construct the fundoplication. In the group not undergoing short gastric vessel division, the anterior wall of the gastric fundus was used for the fundoplication, rather than its apex. Thus, two different constructs of fundoplication were used in the two patient groups. Importantly, the fundus was not fully mobilized in either group.

There are several issues for consideration by the readers of Annals of Surgery. The first is the question ‘What is a Nissen fundoplication?‘ Appropriately, this was the title of an article published by Glynn Jamieson in 1984. ⁵ The technique of the fundoplication described by Nissen in 1956 ⁶ was to mobilize the esophagus, lesser curvature of the stomach, and then approximate the posterior wall of the fundus to the anterior wall of the fundus. This technique was subsequently modified by Nissen’s group to wrap the anterior wall of the fundus around the lower esophagus, creating nearly a spiral valve. ⁷ The short gastric vessels were not divided in either of these operations. The latter of these two techniques has been touted as the Rossetti-Nissen, and is the technique used by the Adelaide group in those patients undergoing the “Nissen” fundoplication in the absence of short gastric vessel division.

What most surgeons term the ‘Nissen‘ fundoplication today is the “short, floppy” Nissen fundoplication (popularized by Donahue et al.), entailing full mobilization of the fundus and using its lateral wall to be the lead point of the wrap around the esophagus. ⁸ When using the apex of the fundus to create the fundoplication, it is nearly always necessary to divide the short gastric vessels and mobilize the fundus to eliminate rotational tension at the suture line. Because the Rossetti-Nissen uses the anterior wall of the fundus for the wrap, it is usually possible to avoid posterior and lateral mobilization of the fundus, yet minimize this tension. When performed by experienced surgeons, the Rossetti-Nissen fundoplication results in excellent outcomes, as has been documented in several case series ⁹ and the prospective randomized trials cited above. ^1-4 However, choosing the correct part of the fundus to use for the wrap is difficult and truly an art, one that is unfamiliar to most general surgeons.

Especially when considering matters of surgical technique, there is a bias giving much greater weight to the outcomes of randomized trials than to the objective assessment of evidence accumulated during extensive clinical experience. These randomized trials of technique, however, are also biased as noted above. There have been several reports comparing outcomes of patients undergoing Nissen fundoplication with and without mobilization of the fundus. Recognized experts in anti-reflux surgery published many of these clinical series. Although most data were obtained in retrospective fashion, and sometimes as a continuation of the learning curve, the experience is nonetheless of value. In a landmark study published in 1986, DeMeester et al. related their experience with 100 consecutive Nissen fundoplications for gastroesophageal reflux disease. ¹⁰ In this group of patients with gastroesophageal reflux disease and no evidence of stricture or esophageal dysmotility, a variety of techniques was used to construct the fundoplication. In analyzing the functional outcomes, mobilization of the gastric fundus increased the incidence of swallowing-induced lower esophageal sphincter (LES) relaxation and resulted in less dysphagia.

The application of laparoscopic techniques to antireflux surgery has markedly increased the number of fundoplications performed over the last decade. ¹¹ Many large series of laparoscopic antireflux surgery have been published, attesting to the safety and efficacy of the procedure. Several series of laparoscopic Nissen fundoplication have addressed the issue of clinical outcome in relationship to the technical details of the procedure. Three articles published in 1996 compared the outcomes of Nissen fundoplication performed either with or without mobilization of the gastric fundus. In each series, fundic mobilization was performed when it was determined that a tension free wrap could not be performed without division of the short gastric vessels. In the series of Hunter and Swanstrom, new onset dysphagia was significantly more common at one and six months postoperatively and esophageal dilatation was performed more frequently in those patients undergoing the Rossetti-Nissen fundoplication. ¹² Dallemagne et al. presented a clinical series of reoperative laparoscopic antireflux procedures and noted that the Rossetti-Nissen fundoplication was associated with a higher rate of failure, particularly due to severe dysphagia. ¹³ Wu et al. reported secondary interventions (esophageal dilatation and/or laparoscopic reoperation) to be significantly more common in patients who did not undergo division of the short gastric vessels. ¹⁴ Finally, a recent analysis of all English language journal articles of laparoscopic fundoplications encompassing more than 10,000 antireflux procedures was published. ¹¹ The rate of persistent dysphagia was found to be significantly less when the short gastric vessels were divided. Thus, in most observational trials and literature reviews, it appears that mobilization of the gastric fundus does improve outcome following laparoscopic antireflux surgery.

There are a number of theoretical reasons for dividing the short gastric vessels on a routine basis during laparoscopic antireflux surgery. The primary reason to mobilize the fundus is to decrease the rotational stress of the fundus encircling the distal esophagus. ‘Non-dilatable dysphagia‘ following Nissen fundoplication can be caused by a twist of the distal esophagus due to traction exerted by the wrapped fundus. ^12,14 If one is using the lateral apex of the fundus to wrap around the distal esophagus, the fundus must be mobilized in most patients to avoid tension on the wrap. When division of the short gastric vessels and fundic mobilization is performed in all patients, the procedure becomes routine and technically easier than if it is performed sporadically. The use of newer energy sources for dividing the fundic attachments has made this maneuver easier, less risky, and faster than when performed using clips and sharp division. ¹⁵ More importantly, during the performance of the “short floppy” Nissen fundoplication it is important to identify the lateral border of the fundus of the stomach and wrap this area around the lower esophagus. Division of the short gastric vessels precisely identifies the location of the lateral border of the fundus, a distinction that in inexperienced hands may be more difficult than one would expect. Mobilization of the fundus also facilitates dissection of the posterior aspect of the gastroesophageal junction and the base of the left crus of the diaphragm, thereby simplifying the creation of a large space posterior to the esophagus under direct vision.

The foregoing discussion begs the question: do the short gastric vessels need to be divided during the performance of a laparoscopic Nissen fundoplication? Certainly there is ample evidence, including that presented by the prospective randomized trial of O’Boyle et al., ¹ that in the hands of experts experienced in performing the Rossetti-Nissen fundoplication, division of the short gastric vessels is not necessary to obtain good postoperative clinical outcomes. However, the “short floppy” Nissen fundoplication should probably be done with routine fundic mobilization. Given the vagaries of eponymous operations, prospective randomized trials do not always answer the perceived question and objective appraisal of the experience of clinical surgeons is also of value. Surgeons must understand the nuances of the fundoplication technique that they use and perform them well. Since antireflux procedures are functional operations, the long-term clinical outcome must be excellent in order to compete with today’s medical treatments for gastroesophageal reflux.

For the practicing general surgeon performing “short, floppy” laparoscopic Nissen fundoplications: regarding the short gastric vessels, divide and conquer!