Nissen fundoplication is a laparoscopic procedure performed for patients with gastroesophageal reflux disease GERD. Many patients with reflux can be treated with conservative treatments. Medicine and lifestyle changes can help decrease stomach acid production. However, some patients are unresponsive to medication, have many problems taking medicine, or are unresponsive to lifestyle changes. If these patients continue experiencing severe symptoms from the reflux of stomach juices such as regurgitation or incomplete healing of their esophagus they may qualify for surgery. The surgery treats the GERD of the patient by addressing the problem that occurs where the esophagus and stomach meet. When the mechanism that prevents stomach acid from flowing upwards (the esophageal sphincter) fails, the acid will reflux up into the esophagus, causing damage. A surgeon performing a Nissen fundoplication wraps a portion of the stomach known as the fundus around the lower esophageal sphincter and sutures it to itself. When correctly performed, Nissen fundoplication will prevent further reflux with minimal side effects, ending the need for long-term treatment with medicine.
Before the procedure can be performed the patient needs to undergo several investigations such as an upper endoscopy and a barium swallow x-ray. These will help assess any narrowing in the esophagus and locate any present Hiatal hernias, which are known to exacerbate reflux disease. Another investigation, esophageal manometry, measures pressures generated in the esophagus and the lower esophageal sphincter. This test is used to make sure the patient is free of conditions within the esophagus that mimic reflux disease but are treated entirely differently.
The part of the stomach that is closest to the entry to the esophagus (fundus) is gathered, coiled, and sutured around the lower end of the esophagus and the lower esophageal sphincter. As a result, there is increased pressure at the lower end of the esophagus, recreating the “one-way valve” that is meant to prevent acid reflux. If the patient is one of the 80% of GERD patients who also suffers from a hiatal hernia (when the upper part of your stomach pushes upward through the diaphragm and into the chest region), the hernial sac will be pulled down from the chest and sutured so that it remains within the abdomen. The opening of the diaphragm through which the esophagus passes through the chest into the abdomen may also be tightened. Nissen fundoplication can be done with a large incision in the abdomen or chest, or laparoscope, which requires several small punctures in the abdomen. Laparoscopic methods have a speedier recovery and less post-operative pain.
Risk Factors with Nissen Fundoplication
Most people who get laparoscopic surgery get improved symptoms and can let the esophagus heal naturally. Like any surgical situation, risks of anesthesia and risks of bleeding or infection are possible. There is also a possibility that over time symptoms may come back, requiring either medicine or another operation.
Surgery can also cause new and troublesome symptoms. Over time, some patients develop complications following fundoplication surgery.
- The esophagus sliding out of the bound portion of the stomach, removing the support that the valve (lower esophageal sphincter) needed.
- A difficulty swallowing because the stomach is bound too high or too tightly around the esophagus.
- Recurring heartburn.
- Bloating and discomfort from the gas buildup caused by being unable to burp.
- Excess flatulence.
Alternatives to Nissen Fundoplication
Fundoplication is the standard surgical option for patients with GERD. Endoscopic (using long flexible tubes that are swallowed by patients) methods for treating GERD are developing but hardly come close replacing the need for fundoplications. In one endoscopic method for GERD an apparatus is inserted that delivers an electrical current to the lower esophageal sphincter, causing it to tighten itself through scarring. In another endoscopic method, sutures are placed in the sphincter to tighten it. Although endoscopic methods offer a simpler treatment style, they are being performed and evaluated at a limited number of centers until questions about their safety, effectiveness, and endurance as a solution for GERD have been answered.
- Keep your stomach from stretching. Eat small frequent meals, avoid large amounts of liquid, stay upright for 1-2 hours after meals, eat slowly and take small bites, avoid crusty bread, sticky, gummy, or doughy foods, and eat desserts or sugar at the end of your meal to avoid “dumping syndrome.”
- Avoid gas. Do not drink through a straw, chew gum, tobacco, or chew with your mouth open. These actions cause you to swallow air and produce excess gas in your stomach.
- Slowly advance from your doctor’s clear liquid diet to a full liquid diet to a soft diet. your doctor will advance your diet depending on your progress after surgery.