Laparoscopic Nissen Fundoplication
The Nissen fundoplication is performed on the intrabdominal oesophagus and stomach.The oesophagus passes through a hole in the diaphragm at a point called the hiatus. A "hiatal hernia" occurs when this opening is large enough to allow the stomach to move up into the chest. Most people who have a haitus hernia do not have symptoms.
The stomach produces lots of hydrochloric to break down food. It has a number of mechanisms to protect itself from theis acid. The oesophagus however, is not equipped to prevent injury from prolonged exposure to the acid reflux. When acid from the stomach finds its way into the oesophagus, it is usually cleared quickly by oesophageal contractions.
If the acid is not cleared, patients may develop heartburn, chest pain, cough, difficulty swallowing and or regurgitation. Eventually these episodes may lead to injury and stricture (narrowing) formation. These events are collectively known as gastrooesophageal reflux disease (GORD). The treatment of GORD starts with life style modification eg.,
- Weight loss
- Smoking cessation
- Reduced fatty food intake
- Reduced alcohol intake
- Reduced consumption of caffeinated and carbonated drinks
- Elevation of the head of the bed during sleeping
- No oral intake four to six hours prior to going to sleep
and medicines to switch of acid production eg the proton pump inhibitor omeprazole.
When patients fail to respond to these non-operative treatments or go on to develop severe oesophageal injury (eg., Barrett's & stricture) surgery in the form of an antireflux procedure is appropriate. The Nissen fundoplication is the commonest.
Before considering surgical treatment patients undergo,-
- Oesophageal manometric & 24-hr pH evaluation
While not always available these investigations not only confirm the diagnosis, but also lead to appropriate selection of patients for surgical repair. In particular, biopsies from areas of suspected Barrett's epithelium may document the presence of severe dysplasia or carcinoma. In such cases, an antireflux procedure alone would be inappropriate and other interventions such as resection or close endoscopic surveillance might be indicated.
Upper gastrointestinal endoscopy may also identify other oesophagogastric mucosal abnormalities other than GORD. A normal 24hour intra-oesophageal pH study would suggest an alternate diagnosis and lead to additional diagnostic investigations. Finally, abnormal peristalsis on esophageal manometric study may suggest a significant risk of dysphagia following fundoplication.
Indications for Surgery
Surgical therapy should be considered in those individuals with documented GORD who:
- have failed medical management
- opt for surgery despite successful medical management (due to life style considerations including age, time or expense of medications, etc.)
- have complications of GORD (e.g. Barrett's/stricture; grade 3 or 4 oesophagitis
- have "atypical" symptoms (asthma, hoarseness, cough, chest pain, aspiration) and reflux documented on 24 hour pH monitoring.
Before the widespread use of laparoscopic techniques, the Nissen fundoplication was performed through a large incision in the middle of the abdomen, extending from just below the ribs to the belly button. Patients would generally stay in the hospital for between 7-10 days and their recovery at home was between 6-12 weeks. The use of laparoscopy has reduced the in-hospital stay to an average of 2 days. Most return to work in about 3 weeks.
The procedure is performed under general anesthesia. Five small incisions are made in the abdomen. One is used for the laparoscope, the other four are used to retract and manipulate structures in the abdomen. The stomach and the intra-abdominal oesophagus are first freed from their attachments. The hiatus is then tightened with 2-3 sutures to prevent the fundoplication from migrating into the chest.
The "fundus" (hence the term fundoplication) of the stomach which lies on the left of the oesophagus and main portion of the stomach is wrapped around the back of the oesophagus (see above) until it lies once again in front of this structure. The portion of the fundus that is now on the right side of the esophagus is sutured x3 to the portion on the left side to keep the wrap in place.
When completed, the fundoplication resembles a buttoned shirt collar. The collar is the fundus wrap and the neck represents the oesophagus imbricated into the wrap. This has the effect of creating a one way valve in the esophagus to allow food to pass into the stomach, but prevent stomach acid from flowing into the oesophagus and thus prevent GORD.
Any surgery has risks of infection, haematoma (blood clot) changes in sensation, pain and problems with wound healing. Of course, as much as possible is done around the time of your operation to minimise these risks. Nonetheless, a small proportion of patients experience problems. In very few patients the spleen may have to be removed because of injury at operation. Rarely, the oesophagus or stomach can be injured leading to a leakage of stomach content into the abdominal cavity. This can be a life threatening complication.
Following the Surgery:
When you return to the ward you will be very drowsy, this is normal and the effect of the general anaesthetic. The nursing staff will be recording your blood pressure; pulse and breathing rate at regular intervals until you are fully awake. Your wounds will be covered with dressings and kept clean and dry for 24 hours. The dressings can be removed the day after the operation.
Eating and drinking:
Your recovery will be quicker if the operation is done laparoscopically and this includes resuming eating and drinking. Usually, you will resume drinking the morning after the operation and eat a very soft diet later that day. In the first few days some people encounter difficulty swallowing. Food sometimes gets stuck for a few minutes in the gullet, which can be very uncomfortable. This is due to the swelling, which occurs at the operation site and also the spasm of muscles.
To avoid this and to allow time for healing we would advise you to avoid bread (including pizza) roast, boiled potatoes, chips and lumpy pieces of meat or fish for the first 4 weeks. It is a good idea to start with sloppy/pureed foods and progress onto more solid foods as your tolerance increases. Food should be cut into small pieces and chewed well before swallowing. You can also assist the passage of food into the stomach by drinking small sips of water with your meals. Drink slowly as it may be difficult to drink large quantities at once.
It is common after a laparoscopic operation to experience some pain in your shoulder. This is due to the stretching of the diaphragm. Painkillers can be given to help to reduce the discomfort. It is important to take painkillers since, if you are in pain, this will delay your recovery.
How well does it work?
When performed by a highly experienced surgeon, surgery is successful 50- 90% of cases. Successful surgery relieves GORD symptoms and oesophagitis. However, there is little information on whether fundoplication surgery is stable and effective over the long term.
Surgery does not completely eliminate in everyone the need to take medicine to control any remaining symptoms. One study, 62% of people who had surgery were still taking medications to control reflux symptoms. However, they were less likely to need to take their medications regularly, and when they do not take medications, their remaining symptoms are likely to be less severe.
While some studies indicate that laparoscopic fundoplication improves GORD symptoms in 76% to 98% of people who have the surgery, no studies have proven that laparoscopic fundoplication surgery is effective in maintaining healing of the esophagus over the long term.
About 10% to 20% of the people who have surgery to relieve GORD symptoms continue to have symptoms or develop new problems (such as difficulty swallowing, intestinal gas, or bloating) after the surgery. These continuing or new symptoms may or may not respond to treatment with medications. Also, one study showed that 16% of the people needed second operations within 10 to 12 years to deal with complications caused by the first surgery!
Side Effects of the Surgery:
It is wise to remember that all surgery has side effects and some of these have been mentioned already. The specific ones relating to anti-reflux surgery include:
Difficulty in swallowing solid food
Feeling full after small meals
Difficulty burping and vomiting
These side effects are very common in the first 6 weeks after surgery, but disappear in the majority of patients. For some people, about 5%, the side effects of surgery (bloating caused by gas buildup, swallowing problems, pain at the surgical site) are as bothersome as their original GORD symptoms.
DIET: For the first few days stay on a full or thick liquid diet. This includes such things as milkshakes, puddings, soups, mashed potatoes etc. If you tolerate this advance to soft foods (ground meat, chicken, fish, pasta, soft vegetables, etc.).
- DIETARY RESTRICTIONS: Avoid carbonated drinks, beer, crusty breads, bagels, tough meats and raw vegetables.
MEDICATIONS: Stay on your acid reducing medication for one month. You will be given pain medication when you are discharged from the hospital. Use this as needed.
CARE OF YOUR TROCAR WOUNDS (INCISIONS): You may shower 48 hours after your surgery. Wash over your trocar sites gently with soap and water, let the water rinse over it and pat it dry. Stiches are placed just beneath the surface of the skin and are absorbable and will not need to be removed. The steristrips placed over each trocar site will fall off on their own, usually 7-10 days after surgery. You should notify your GP if you notice any redness at the sites or if a trocar site opens up
ACTIVITY: You can drive 1 week after surgery. However, do not drive if you are taking pain medication. Walking is permitted and encouraged. Do not do any heavy lifting for 2 weeks.
FOLLOW UP: You should schedule an appointment when you get home from the hospital to see your surgeon 4-8 weeks after surgery. If you have any concerns or questions about your diet, medications or general post-operative recovery, contact your surgeons secretary.
CALL YOUR GP if you have any of the following: Persistent nausea and vomiting, increased pain, fever, infection of trocar sites (redness or drainage of sites) or severe bloating.
We have performed over 100 laparoscopic antireflux procedures here in Bristol. The majority have been Nissen fundoplications. No patient has died from the procedure. The success of the surgery, as measured by relief of symptoms is more than 90%. Laparocopic Nissen fundoplication is a very safe and effective treatment for GORD when medical management fails.
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