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Tuesday, June 6, 2017

Nissen Fundoplication

A Nissen fundoplication, or laparoscopic Nissen fundoplication when performed via laparoscopic surgery, is a surgical procedure to treat gastroesophageal reflux disease (GERD) and hiatal hernia. In a fundoplication, the gastric fundus (upper part) of the stomach is wrapped, or plicated, around the lower end of the esophagus and stitched in place, reinforcing the closing function of the lower esophageal sphincter. The esophageal hiatus is also narrowed down by sutures to prevent or treat concurrent hiatal hernia, in which the fundus slides up through the enlarged esophageal hiatus of the diaphragm.

In a Nissen fundoplication, also called a complete fundoplication, the fundus is wrapped the entire 360 degrees around the esophagus. In contrast, surgery for achalasia is generally accompanied by either a Dor or Toupet partial fundoplication, which is less likely than a Nissen wrap to aggravate the dysphagia that characterizes achalasia. In a Dor (anterior) fundoplication, the fundus is laid over the top of the esophagus; while in a Toupet (posterior) fundoplication, the fundus is wrapped around the back of the esophagus.

The procedure is now routinely performed laparoscopically. When used to alleviate gastroesophageal reflux symptoms in patients with delayed gastric emptying (gastroparesis), it is frequently combined with modification of the pylorus via pyloromyotomy or pyloroplasty. (You can read that here in another blog article of mine: http://www.emilysstomach.com/2017/06/pyloric-stent-pyloroplasty.html)


This is a completed Nissen Fundoplication in Watercolors:
Source: By Dana Hamers - Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=20453728
Source: http://en.wikipedia.org/wiki/Nissen_fundoplication


This is the Nissen Fundoplication Procedure:
Source: Original Artwork by James P. Gray, M.D. 2007 (author)



The doctor that I saw that the Mayo Clinic wanted me to have this surgery done so that it would stop my vomiting. However, he concluded that since I vomit so violently, I would undo the surgery. A mom who reads my blog and has a son with gastroparesis, was nice enough to share his story with me about the Nissen he had done. When my doctor said that it would stop vomiting, he was wrong. His story is below,


"Hi, my 17 year old son had the Nissen procedure last year. He too violently throws up. The surgery went well but he said out of his 33 surgeries it was the most painful after. He went through the recovery process not realizing until about a week after that he could not even swallow water without it coming right back up.

He lost weight quickly and was very dehydrated so at his check up appointment the hospitalized him. The Nissen was too tight and nothing was going to his stomach. The doctor did a scope and stretched the area. That helped for a bit but they had to go back and stretch it a second time.

That was the last stretch they had to do. They said the Nissen would make it almost impossible for him to throw up. Boy were they wrong. He still throws up most every time he eats. By the way he has GP (gastroparesis) and has an electric stimulator in his stomach. Amanda S."


I also know a few people with gastroparesis who have had this surgery done and they are miserable now. They are unable to vomit at all. That worries me, personally, because what if you get food poisoning and need to vomit to get it out? What do you do then?


"Gastroparesis Following Nissen Fundoplication And Hiatal Hernia Repair

Nissen fundoplication with hiatal hernia repair is the most reliable and most effective treatment of GERD or acid reflux disease. The procedure is also very safe with less than 1% complication rate. Gastroparesis or delayed gastric emptying is a poorly understood medical disorder. Gastroparesis results from abnormal gastro-duodenal motility resulting in nausea, vomiting, bloating, epigastric pain and early satiety. Gastroparesis can also contribute to acid reflux disease. GERD is a multi-factorial problem and is closely related to gastric motility. Indeed, gastric fundus compliance, relaxation, food accommodation and luminal pressure affects transient lower esophageal sphincter relaxation, TLESR. TLESR is believed to be the main cause of acid reflux. It is not surprising for gastroparesis patients to suffer from heartburn and other GERD related symptoms. In fact, both GERD and gastroparesis may represent different aspects of the same problem related to esophago-gastro-intestinal dysmotility.

Many GERD patients undergoing Nissen fundoplication and hiatal hernia repair surgery may also have undiagnosed gastroparesis. Around 40% of GERD patients suffer from delayed gastric emptying. Nissen fundoplication increases gastric emptying and is sometimes associated with dumping especially in children. Wrapping the fundus around the esophagus decreases gastric compliance possibly leading to increased gastric emptying. The same mechanism of action may also be at play in the case of sleeve gastrectomy. By resecting the gastric fundus, gastric compliance decreases and emptying increases. Consequently, Nissen surgery improves gastric emptying and it contributes to gastroparesis symptom resolution.

In a minority of patients, Nissen surgery is associated with post-operative gastroparesis symptom development. These patients develop nausea, bloating, and pain in the first few days after Nissen surgery. It is unclear whether the surgery itself causes de novo gastroparesis or if it exacerbates an already existing problem with gastric emptying. It has always been assumed that vagal nerve injury results in gastric stasis and failure of the pylorus to relax. Pyloromyotomy has also been advocated in vagotomy cases. Swanstrom et al published a study in 2009 in Archives of Surgery titled “Outcomes of Nissen Fundoplication in Patients with Gastroesophageal Reflux Disease and Delayed Gastric Emptying”. He recommends the addition of pyloroplasty to Nissen fundoplication in cases of delayed gastric emptying. In my experience, pyloromyotomy, like other drainage procedures, has minimal effect on gastric emptying. Gastric emptying is a highly coordinated myo-electrical process. Many feedback signals, in addition to the vagus nerve, modulate this activity. It is unlikely that post-operative gastroparesis is the sole result of vagal nerve injury.

In 2004, a study published by Masclee et al, in the Annals of Surgery showed that laparoscopic fundoplication increases gastric emptying independent of vagal nerve function. The authors nicely showed that 10% of fundoplication patients developed vagal nerve dysfunction post-operatively without affecting gastric emptying or the efficacy of fundoplication in controlling acid reflux. The etiology of gastric stasis is following Nissen surgery remains unclear. There are no established treatment guidelines for gastroparesis. Medications, gastric pacing and drainage procedures are not effective solutions. Subtotal gastrectomy and gastric bypass are associated with poor outcomes. Longitudinal gastrectomy with or without duodeno-jejunostomy seems to be very effective in curing gastroparesis. I have developed this technique several years ago and I have had the chance to apply it on 4 patients so far. Last year, a young man with gastroparesis following fundoplication surgery at an outside institution presented to my office. I performed a longitudinal gastrectomy while preserving the fundoplication and antrum. His symptoms improved immediately. A post-operative UGI study on day one after surgery showed normal gastric emptying. The patient is 8-month post-op now and still doing great.

In summary, gastroparesis and gastric emptying remain poorly understood. However, a tailored longitudinal gastrectomy, even in the presence of a fundoplication, may be an effective and durable solution for gastroparesis. Additional studies are needed to establish this approach as the standard of care treatment for gastroparesis."
Source: http://houstonheartburn.com/gastroparesis-following-nissen-fundoplication-and-hiatal-hernia-repair/



Source: http://www.laparoscopicsurgeonmumbai.com/precautions-nissen-laparoscopic-fundoplication-surgery-gerd/



WebMD says,

"Surgery Overview

During fundoplication surgery, the upper curve of the stomach (the fundus) is wrapped around the esophagus camera and sewn into place so that the lower portion of the esophagus passes through a small tunnel of stomach muscle. This surgery strengthens the valve between the esophagus and stomach (lower esophageal sphincter), which stops acid from backing up into the esophagus as easily. This allows the esophagus to heal.

This procedure can be done through the abdomen or the chest. The chest approach is often used if a person is overweight or has a short esophagus.

This procedure is often done using a laparoscopic surgical technique. Outcomes of the laparoscopic technique are best when the surgery is done by a surgeon with experience using this procedure.

If a person has a hiatal hernia, which can cause gastroesophageal reflux disease (GERD) camera.gif symptoms, it will also be repaired during this surgery.



What To Expect After Surgery

If open surgery (which requires a large incision) is done, you will most likely spend several days in the hospital. A general anesthetic is used, which means you sleep through the operation. After open surgery, you may need 4 to 6 weeks to get back to work or your normal routine.

If the laparoscopic method is used, you will most likely be in the hospital for only 2 to 3 days. A general anesthetic is used. You will have less pain after surgery, because there is no large incision to heal. After laparoscopic surgery, most people can go back to work or their normal routine in about 2 to 3 weeks, depending on their work.

After either surgery, you may need to change the way you eat. You may need to eat only soft foods until the surgery heals. And you should chew food thoroughly and eat more slowly to give the food time to go down the esophagus.



Why It Is Done

Fundoplication surgery is most often used to treat GERD symptoms that are likely to be caused in part by a hiatal hernia and that have not been well controlled by medicines. The surgery may also be used for some people who do not have a hiatal hernia. Surgery also may be an option when:

Treatment with medicines does not completely relieve your symptoms, and the remaining symptoms are proved to be caused by reflux of stomach juices.

You do not want or, because of side effects, you are unable to take medicines over an extended period of time to control your GERD symptoms, and you are willing to accept the risks of surgery.

You have symptoms that do not adequately improve when treated with medicines. Examples of these symptoms are asthma, hoarseness, or cough along with reflux.



How Well It Works

In most people who have laparoscopic surgery for GERD, the surgery improves symptoms and heals the damage done to the esophagus.

Over time, some people have symptoms come back, have esophagitis come back, need to take medicine for symptoms, or need another operation.

Surgery can cause new and troublesome symptoms. Over time, some people have trouble swallowing, have increased flatulence (gas), and/or have trouble belching.




Risks or complications following fundoplication surgery include:

Difficulty swallowing because the stomach is wrapped too high on the esophagus or is wrapped too tightly.

The esophagus sliding out of the wrapped portion of the stomach so that the valve (lower esophageal sphincter) is no longer supported.
Heartburn that comes back.

Bloating and discomfort from gas buildup because the person is not able to burp.

Excess gas.

Risks of anesthesia.

Risks of major surgery (infection or bleeding).

For some people, the side effects of surgery-bloating caused by gas buildup, swallowing problems, pain at the surgical site-are as bothersome as GERD symptoms. The fundoplication procedure cannot be reversed, and in some cases it may not be possible to relieve the symptoms of these complications, even with a second surgery.




What To Think About

GERD can be annoying and even painful. But it is not a dangerous disease. For any GERD treatment to be worth trying, it needs to be very safe. For many people, especially those who have few problems taking medicine, surgery is not a good choice.

But when fundoplication surgery is successful, it may end the need for long-term treatment with medicine. When you are deciding between surgery and treatment with medicine, weigh the cost, risks, and potential complications of the surgery against the cost and inconvenience of taking medicine.




GERD: Which Treatment Should I Use?

Before surgery, additional tests will usually be done to be sure that surgery is likely to help cure GERD symptoms and to diagnose problems that could be made worse by surgery.

Second surgeries are harder to do, are less successful, and are more risky. So it is extremely important that the first procedure be considered carefully and be done by an experienced surgeon who is more likely to be successful the first time.



Surgery to treat GERD is rarely done on people who:

Are older adults, especially if they have other health problems in addition to GERD.

Have weak squeezing motions (peristalsis) in the esophagus. These motions are important to move food down the esophagus to the stomach. Surgery may make this problem worse, causing food to get stuck in the esophagus.

Have unusual symptoms that might be made worse by surgery.

In special cases, other surgeries such as partial fundoplication or gastropexy may be done instead of fundoplication surgery.



Source: http://www.bariatricinnovationsatl.com/acid-reflux-surgery



References and Citations:

Lundell L, et al. (2007). Seven-year follow-up of a randomized clinical trial comparing proton-pump inhibition with surgical therapy for reflux oesophagitis. British Journal of Surgery, 94(2): 198-203.


Other Works Consulted:

Galmiche J-P, et al. (2011). Laparoscopic antireflux surgery vs esomeprazole treatment for chronic GERD. JAMA, 305(19): 1969-1977.



Credits:

By: Healthwise Staff
Primary Medical ReviewerAdam Husney, MD - Family Medicine
Specialist Medical ReviewerPeter J. Kahrilas, MD - Gastroenterology

Current as of November 20, 2015"



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