Fundoplication encompasses a well-established role within the treatment of gastroesophageal reflux disease. It is established that open/laparoscopic Nissen's fundoplication achieves a decent long-term outcome for many patients undergoing surgery for reflux disease. [1-5]. Unfortunately, however, some patients undergoing Nissen's fundoplication are troubled by side effects including dyspepsia, bloating, and inability to belch. Besides, the procedure needs a learning curve and also the duration of surgery is more with longer hospital stay and associated financial burden. Due to these problems, anterior and posterior partial fundoplication techniques were developed. [6,7,8]. Randomized trials have shown that partial fundoplication techniques were related to reduced incidence of adverse effects and with good reflux control at short term as well as long term follow-up. [9-14]. Results from a randomized trial shows that, acid, weakly acidic, liquid and mixed reflux episodes are more common after anterior 180° fundoplication than after Nissen fundoplication. On the contrary, gas reflux and gastric belching and patient satisfaction are similar for both procedures. Mean lower esophageal sphincter (LES) resting and relaxation nadir pressure are lower after anterior fundoplication. Overall, these findings suggest less effective reflux control after anterior 180° partial fundoplication, offset by less dysphagia, leading to a clinical outcome that is equivalent to Nissen fundoplication at late follow-up [15]. Systematic meta-analysis of randomized trials has shown that laparoscopic Nissen's fundoplication and 180° laparoscopic anterior fundoplication are equally effective in controlling reflux symptoms and obtain a comparable prevalence of patient satisfaction. 180° laparoscopic anterior fundoplication can reduce the incidence of postoperative dysphagia while this is offset by a higher risk of reoperation for recurrent symptoms. The risk of recurrent symptoms should need to be balanced against the risk of dysphagia when surgeons choose surgical procedures for each individual with GERD [16]. More studies have shown that at 1 and 5 years post-surgery, dysphagia and gas-related symptoms are lower after 180° laparoscopic anterior fundoplication than after laparoscopic Nissen's fundoplication, and esophageal acid exposure and esophagitis are similar, with no differences in heartburn scores, patient satisfaction, dilatations, and reoperation rate.

The questionnaire was initially mailed to each patient; if not returned, the patient was located and data collected by telephone interview. A concentrated effort was made to secure follow-up information for each patient who had undergone surgery to attain complete follow-up.

The presence or absence of heartburn, dyspepsia was assessed using a 0-10 visual analogue scale (0 indicates no symptoms, 10 indicates severe symptoms). Overall satisfaction with the outcome of the procedure was also determined employing a 1-10 visual analogue scale. (0 indicates unsatisfied, 10 indicates satisfied). The presence or absence of bloating and belching ability to alleviate abdominal distension by belching and eating a normal diet was determined with a yes/no questionnaire. Patient's opinion of whether they thought that they had made the right decision to undergo surgery was also sought.

Details about adverse outcomes, including postoperative complications, hospital readmissions, surgical revision were also recorded. Postoperative esophageal manometry, 24 hours ambulatory pH monitoring, endoscopy performed only in symptomatic patients. For this reason, these data weren't formally analyzed in this report. They were however taken into consideration when determining whether patients had developed recurrent reflux during follow-up.

Outcome data were analyzed to see the short-term and long-term clinical efficacy of the anterior 180° partial fundoplication procedure and also the incidence of adverse outcomes and overall satisfaction with surgical outcome. From January 1, 2013 to March 31, 2021, 228 laparoscopic anterior 180° partial fundoplication procedures were performed by us. These patients constituted the study group.

The present study was approved by the Institutional Ethics Committee, SevenHills Hospital Vizag, India.

Table 1: Age and Gender Distribution

Figure 1: Surgery performed in patients with Achalasia Cardia

Since undergoing the anterior fundoplication 2 patients died during the follow-up and 1 patient died during the post-operative recovery. During follow-up, causes of death in 2 patients were due to Cardiovascular accident and Myocardial infarction. A further surgical procedure was done in 1 patient due to dyspepsia.

The esophageal hiatus was widened by removing 1 hiatal repair suture. Besides, early post-operative dyspepsia sufficient to require endoscopic dilation occurred in 1 patient. The patient needed several dilations before adequate swallowing was achieved.

Outcome and selected subgroup long-term outcome (≥5 years) were done. Follow-up data were not available for patients who could not be located at the time of the present study. Clinical outcome data at ≥5 years were available for 85 patients.

This group excludes 3 patients who died, 5 who were converted to open procedure, and 110 patients who were unavailable for follow-up (<5 years of follow-up). Gastroesophageal reflux disease symptoms were well controlled in 186 patients at follow-up and in 80 patients at long-term follow-up in the selected sub-group.

Figure 2: Analog score for heartburn before surgery and late follow-up (5 years)

Figure 3: Analog score for dyspepsia before surgery and late follow-up (5 years)

Since Nissen's [18] original description, the 360° total fundoplication has been the most common surgical procedure used for the treatment of gastroesophageal reflux. Although initially performed using an open abdominal or thoracic surgical approach, most of Nissen's fundoplications are now performed laparoscopically. Previous reports of outcome including long-term outcome following open Nissen fundoplication have confirmed a success rate of approximately 90% at 5-10 years after surgery. [1,13]. Most recently, longer outcomes following laparoscopic Nissen fundoplication have also been reported. [4,19,20]. It is now widely accepted that the Nissen fundoplication achieves an effective barrier to reflux in most patients at medium to long-term follow-up. Unfortunately, however, the new anti-reflux barrier is more effective than a lower esophageal sphincter in normal patients, which means that some patients will be troubled by adverse effects following surgery, such as persistent dyspepsia, flatulence, gas bloat, and inability to belch. [14,21]. In some of these patients, adverse effects are sufficiently troublesome to interfere with the quality of life, which can result in a poor overall outcome despite the fundoplication having provided effective control of the reflux symptoms. For this reason, anterior and posterior partial fundoplication variants have been developed to reduce the incidence of adverse effects while still achieving effective control of gastroesophageal reflux symptoms. In so many prior studies, it is recognized that anterior fundoplication can achieve effective reflux control but with fewer adverse effects than either Nissen/post partial fundoplication. Early and late clinical data in previous studies is promising with significantly reduced incidence of both dyspepsia and gas-related adverse effects compared to Nissen's fundoplication. The present study was undertaken to determine the short-term and long-term efficacy of anterior fundoplication and see whether lesser complications including dyspepsia and gas bloating are seen in these patients on follow-up. Further, the easy reproducibility, lesser duration of surgery, and early return to home are also studied. Our results show that anterior 180° partial fundoplication is an effective procedure. Reflux remained well controlled in approximately 95% of patients at late follow-up, with less than 5% reporting an analogue heartburn score of 7 or greater.

In the era of open anti-reflux surgery, most follow-up studies failed to determine the outcome for more than 20% of their patients. [1,13,24]. In general, case series of patients undergoing laparoscopic anti-reflux surgery have similar rates of follow-up. [ 4,20]. The exceptions are the 99% follow-up rate in our previously reported 5 to 8-year follow-up after laparoscopic Nissen fundoplication, [3]. and the 100% and 98% 5-year follow-up rates in 2 of our randomized trials. [ 9,14].

Analysis of data from one of those randomized trials demonstrated that clinical outcomes may appear to be better than they are if complete or near-complete follow-up is not obtained. [25]. However, the results reported herein should be interpreted with some caution. It is not appropriate to directly compare these results with outcomes for Nissen fundoplication reported elsewhere because some selection bias was involved with these patients that were not in the randomized trials. Nevertheless, the outcomes are at least consistent with the outcome at 5 years in the previously reported randomized controlled trial of anterior 180° partial fundoplication vs Nissen fundoplication. [9].

Therefore, the larger patient cohort and longer follow-up in the present study support the contention that laparoscopic anterior 180° partial fundoplication is an appropriate procedure for patients with gastroesophageal reflux. Our study might also be criticized for not reporting objective outcome data. Patients were not systematically reevaluated with esophageal manometry, pH monitoring, or endoscopy at late follow-up, and we have therefore limited our report to clinical outcomes. Ultimately, however, the measure of success after a surgical procedure is determined by the patient’s view of the outcome rather than by the results of various investigations.

We conclude, therefore, that laparoscopic anterior 180° partial fundoplication is an appropriate procedure for patients undergoing surgery for gastroesophageal reflux. It has significant reflux-related symptom relief, uncommon post-surgery complications like dyspepsia, inability to belch compared to standard Nissen's fundoplication. This procedure is economical due to less duration of surgery and the duration of hospital stay. Since surgery reproducibility is simpler than Nissen's, it can be done in a smaller setup.