ABSTRACT

Introduction: The efficacy, safety, and durability of partial fundoplication for the treatment of gastroesophageal reflux disease (GERD) is well established. At our center, we prefer a symmetrical partial 300-degree anterior-posterior fundoplication around the lesser (PF). Recently, we have added an additional row of sutures to recreate the Angle of His (AOH) accentuation before the rotation of fundoplication limbs (PF+) to facilitate the correct identification of anterior and posterior fundoplication limbs. We compared the perioperative and mid-term outcomes between partial fundoplication with and without AOH accentuation.

Methods: We retrospectively analyzed patients who underwent primary elective minimally invasive fundoplication primarily for uncontrolled reflux. We excluded redo procedures and those with non–GERD indications. Patients were stratified into two groups: PF and PF+. The primary outcomes included objective hiatal hernia recurrence, perioperative complication rates, and quality of life (i.e., assessed via GERD-HRQL).

Results: From a total 375 in the cohort, 167 (44.5%) underwent PF+. Baseline patient characteristics were comparable between the two groups. Early postoperative complication rates (6.9% vs. 9.0%, p=0.59) were also similar. All patients who underwent PF fundoplication and 142 (85%) who underwent PF+ fundoplication had were out of surgery at least 12 months by the moment of analysis. Follow-up, including GERD-HRQL and/or barium esophagram, was completed by 74/208 (35.6%), 80/208 (38.5%) and 65/208 (31.2%) patients in the PF group and 74/142 (52.8%), 33/96 (34.4%), and 11/39 (28.2%) patients in the PF+ group at 1, 2, and 3 years after surgery. Objective recurrent hiatal hernia (i.e., >2 cm) noted by barium esophagram, endoscopy, or CT-scans at 1 year were 0/74 and 2/74 in the PF and PF+ groups, respectively, And no recurrences were observed in neither group at 2 and 3 years. The median total GERD-HRQL scores (PF group preop: 32.5 [IQR 13–45], 1-year: 1 [IQR 0–5], and 2-year: 2 [IQR 0–9]; PF+ group preop: 29.5 [IQR 14–46 ], 1-year: 1 [IQR 0–4] and 2-year: 1.5 [IQR 0–1.75]) and overall satisfaction rates (≥8/10) at 1 year (PF: 85.7% vs. PF+: 87.1%, p=1.0), 2 years (PF: 74.2% vs. PF+: 90%, p=0.14), and 3years (PF: 75% vs. PF+: 87.5%, p=0.75) were comparable between the groups.

Conclusion: Both PF and PF+ are safe and effective treatments for GERD, with excellent improvement in symptoms, quality of life, and patient satisfaction over three years. Incorporation of AOH fundoplasty may facilitate the correct creation of the PF fundoplication while maintaining excellent subjective and objective mid-term outcomes.