IS IT IMPORTANT TO DIVIDE THE SHORT GASTRIC VESSELS DURING LAPAROSCOPIC NISSEN FUNDOPLICATION?

Summary/ Background Data: Laparoscopic Nissen Fundoplication (LNF) is the most common antireflux 
operation and can be performed with or without short gastric vessels division (SGVsD). Some series claimed 
that SGVsD minimizes postoperative dysphagia, bloating and inability to belch, while others found similar 
outcomes without SGVsD. 
Objective: This study evaluates the symptomatic and physiologic outcomes among patients with 
gastroesophageal reflux disease (GERD) who underwent LNF with or without SGVsD. 
Design: Retrospective case series. 
Setting: Mansoura Gastroenterology Surgical Center, Mansoura University, Egypt. 
Methodology: Between January 2002 and January 2010, 250 patients (155 males, 95 females) with a mean age 
of 35+10 years with typical symptoms of Gastro-esophageal reflux disease (GERD), adequate motility study 
and positive 24-hour pH studies underwent LNF; 195 (78%) had a satisfactory wrap after careful and 
complete fundal dissection without the need for SGVsD while, 55 (22%) had SGVsD for better creation of a 
floppy wrap. One hundred and eighty patients (150 without division and 30 with) agreed to come for 
reassessment (at least 3 years between their operation and date of contact). Outcome measures included 
assessment of the relief of the primary symptom responsible for surgery, repeated endoscopy, barium study, 
24-hour pH metry and the lower esophageal sphincter (LES) manometry.
Results: In June, 2012 we started to contact all patients (250 cases). By February, 2013 we could contact 180
patients (150 without division and 30 with) agreed to come for reassessment (at least 3 years between their 
operation and date of contact). Division of the short gastric vessels prolonged the mean operative time 
(115±50 vs 90±40 minutes). Relief of the primary symptom responsible for surgery was achieved in 93.3% of 
patients with division and 90% of patients without. Recurrent attacks of abdominal distension were 
documented in 3 patients (10%) with division and 14 patients (9.3%) without division. Occasional Dysphagia 
not present before surgery occurred in 35 patients (19.4%) at 3 months; 7 (23.3%) with division and 28 (18.7%) 
without, and decreased to 14 patients (7.8%) on late follow up; 3 (10%) with division and 11 (7.3%) without 
(four cases had endoscopic dilatation; two with division and two without). Endoscopic esophagitis healed in 
28 of 30 patients (93.3%) with division and 142 of 150 patients (94.7%) without. LES pressures had returned to 
normal in all patients except 3 cases; one with division and 2 without with a mean pressure (17.8mmHg 
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among those with division and 19.1 mmHg among those without) and relaxation (87.5% with division and
84.5% without) nearly similar. 24-hour esophageal acid exposure had returned to normal in 28 of 30 patients 
(93.3%) with division and 140 of 150 patients (93.3%) without. Five cases were reoperated upon: 3 with no 
division; one with tight wrap and 2 with recurrent reflux and wrap migration while, the other 2 cases had 
division; both had recurrent reflux.
Conclusions: Construction of a satisfactory loose complete wrap was possible without the need for SGVsD in 
about 78% of patients. SGVsD lengthens the procedure, adds complexity and expense without adding more 
for the operative outcome. We believe it is unnecessary to divide the short gastric blood vessels routinely 
during LNF.