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Gastric Reflux Surgery

Nissen Fundoplication surgery is a procedure to treat gastro-oesophageal reflux disease (GORD). GORD occurs when stomach contents reflux and enter the lower end of the oesophagus (LES) due to a relaxed or weakened sphincter. GORD is a treatable disease and serious complications may occur if left untreated.

To learn more about this surgery, it is important to understand the upper gastrointestinal function and anatomy.

Normal Anatomy of Upper GI System

All food and drink that we consume are in the form that the body cannot use as nourishment. Digestion is the process by which food and drink are broken down into their smallest parts so that the body can use them to nourish cells and to provide energy. Parts of the upper gastrointestinal (GI) system include:

Oesophagus (Food pipe)

The oesophagus is a muscular tube that connects the pharynx (throat) to the upper end of the stomach. The oesophageal wall is made up of layers of muscle which help push the food into the stomach by waves of peristalsis.

Lower Oesophageal Sphincter (LES)

The lower oesophageal sphincter (LES) is a band of muscles at the junction of the oesophagus (food pipe) and the stomach. LES acts as a “valve” to prevent reflux of acid and chyme (food mixed with acid & digestive enzymes) from the stomach to the food pipe.

Stomach

The stomach, apart from being a storage organ, secretes acid and other digestive enzymes for digestion of food. There is always some acid in the stomach, which normally does not enter the oesophagus, not even when lying down. The mucus lining of the inner wall of the stomach prevents the stomach from being digested from its own acid.

Heartburn

Heartburn is a form of indigestion and the most common symptom when acid from the stomach refluxes into the oesophagus (food pipe). It is the sensation of discomfort in your chest. It is usually temporary and if persistent or long standing (2 or 3 times a week) it could be gastro-oesophageal reflux disease or GORD.

What is GORD?

GORD is a treatable disease and serious complications may occur if left untreated. GORD is a chronic condition where the stomach contents reflux into the oesophagus. Normally, the stomach contents do not enter the oesophagus (food pipe) due to a constricted lower oesophageal sphincter. In GORD, the LES is weak or relaxed, enabling stomach acids to reflux into the oesophagus.

Causes of GORD

The exact cause of what weakens or relaxes the lower oesophageal sphincter in GORD is not known.

However, the following triggers are known to make the reflux worse:

  • Lifestyle - Use of alcohol or cigarettes, poor posture (slouching)
  • Certain medications – NSAIDs (aspirin, ibuprofen), calcium channel blockers, theophylline, nitrates, and antihistamines
  • Diet – spices, pepper, onions, tomato sauce, peppermint, fatty and fried foods, chocolates, drinks with caffeine, and acid foods such as citrus fruits & tomatoes
  • Eating habits - large meals, sleeping or lying down soon after eating

Other contributing factors for GORD include the following medical conditions:

  • Hiatal hernia
  • Pregnancy
  • Obesity
  • Diabetes
  • Rapid weight gain

Symptoms

The main symptom of GORD is heartburn. Heartburn is a form of indigestion. It is usually felt as a burning pain in the centre of the chest.

Other symptoms can include:

  • An acidic, sour taste in the mouth
  • Burning pain in the throat
  • Difficulty in eating
  • Bloating and belching
  • Stomach pains
  • Regurgitating food (when food comes out of your stomach and back up your oesophagus)
  • Nausea and vomiting
  • Vomiting blood
  • Dark tarry stools

Symptoms tend to get worse after eating, especially after a large fatty meal.

Some unusual symptoms may include:

  • Coughing, when lying down
  • Hoarseness or changes in the voice, because the acid gets into the windpipe and voice box (larynx) and irritates it
  • Chest pain

Complications

The oesophageal lining is not meant to withstand acid and repeated reflux of stomach acid can lead to the following conditions:

  • Esophagitis (Oesophageal inflammation)
  • Oesophageal ulcer (break in the lining)
  • Oesophageal stricture (scarring and narrowing at the lower end of the oesophagus near the stomach junction)
  • Pulmonary aspiration (acid in lungs or lung cavity)

Replacement of normal oesophageal lining with abnormal (Barrett's) lining. This condition, Barrett’s oesophagus, is linked with Oesophageal cancer.

Diagnoses

Your doctor usually diagnoses GORD based on your medical history alone, but may ask you to undertake the following tests:

  • Endoscopy: A thin endoscope with a camera on the end is passed down the oesophagus towards the stomach. It enables doctors to see the inside of your oesophagus on a television monitor.
  • Barium X-rays: These are diagnostic X-rays in which barium is used to diagnose abnormalities of the digestive tract. The patient drinks a liquid that contains barium, which will coat the walls of the oesophagus and stomach. X-rays are then taken, which can then show if there are strictures, ulcers, hiatal hernias, erosions, or other abnormalities.
  • Oesophageal manometry: This is a test that measures the function of the lower oesophageal sphincter and the motor function of the oesophagus.
  • PH Study or Acidity test: This is done on the inside of the oesophagus by passing a thin wire through your mouth or nose and into your oesophagus. The wire will measure how acidic your oesophagus is and record the results electronically.
  • Ambulatory 24 hr. PH Probe Study: This study measures the acid that refluxes back up from the stomach. A very thin tube is inserted up through the nostril and then down the throat and oesophagus until it reaches just above the stomach. The tube has a very small probe at the end that will register any acids that are refluxed from the stomach. An x-ray is taken to make sure that the probe has been positioned correctly. The other end of the thin tube is attached to a small computer (small black box) for 12 or 24 hours. During this period you are given a diary sheet to complete, on which you should record the time of each activity that takes place, basically a running history.
  • PH Capsule: This is a new type of pH probe which requires no tube though the nose. It is a sensor that is attached to the lining of the oesophagus, with an endoscope. Often this procedure is carried out at the same time as having an endoscopy (upper GI) performed. The pH sensor sends signals to a portable computer which collects the data about the acid exposure over the usual 24 hrs. There is no removal procedure, the sensor will slowly detach itself from the oesophagus with time and is then passed through a normal stool.
  • Impedance Study: Similar to a standard pH test, but with two probes. One sits in the stomach and the other just above the stomach. The advantage of the dual sensor is that it can detect both acid and alkaline reflux travels. The tube is inserted through the nostril (this can be placed whilst still sedated after an endoscopy), and the other end is attached to a small computer, no bigger than a Walkman.

Conservative Treatment Options

GORD, in general, cannot be cured at present. The principles of GORD treatment are:

  • Reducing reflux
  • Relieving symptoms
  • Preventing damage to the oesophagus

However, in temporary conditions such as in pregnancy, GORD may completely recover following delivery of the baby.

Treatments Options Include

  • Antacids
    • These medications neutralize the acid in the stomach and provide temporary relief for heartburn.
  • Other Medications
    • H2 antagonists or Histamine receptor blockers: These reduce the production of acid in your stomach by blocking a signal that leads to acid secretion.
    • Proton Pump Inhibitors: Proton pump inhibitors (PPIs) are a group of prescription medications that prevent the release of acid in the stomach and intestines. Doctors prescribe PPIs to treat people with heartburn (acid reflux), ulcers of the stomach or intestine, or to decrease excess stomach acid.

Tips for Control

Many people can relieve their symptoms by changing their habits and lifestyle. The following steps, if followed, may reduce your reflux significantly:

  • Don’t eat within 3 hours of bedtime. This allows your stomach to empty and acid production to decrease.
  • Similarly, don't lie down right after eating at any time of day.
  • Elevate the head of your bed 6 inches with blocks. Gravity helps prevent reflux.
  • Split meals or eat small meals. Eating a lot of food at one time increases the amount of acid needed to digest it.
  • Avoid fatty or greasy foods, chocolate, caffeine, mints or mint-flavoured foods, spicy foods, citrus, and tomato-based foods. These foods decrease the competence of the LES.
  • Avoid drinking alcohol. Alcohol increases the likelihood that acid from your stomach will back up.
  • Stop smoking. Smoking weakens the lower oesophageal sphincter and increases reflux.
  • Lose excess weight. Overweight and obese people are much more likely to have bothersome reflux than people of healthy weight.
  • Talk to your health care provider about any medications you are taking. These may aggravate reflux in some people.

These changes may be difficult. Talk to your health care provider about the tips to avoid acid reflux.

Surgical Introduction

If conservative treatment options fail to resolve your GORD, your doctor may recommend a surgical procedure called Nissen Fundoplication. Nissen Fundoplication surgery reinforces the lower oesophageal sphincter’s ability to close and helps to prevent gastro-oesophageal reflux from occurring. The surgery involves wrapping the top part of the stomach, the fundus, around the lower end of the oesophagus and suturing it in place. Sutures are also placed to narrow the hiatus, the opening in the diaphragm that the oesophagus passes through, to prevent or treat concurrent hiatal hernia. Hiatal hernia is a condition that occurs when the upper part of the stomach slides up into the oesophagus.

This surgery can be performed laparoscopically through tiny incisions in the abdomen as opposed to an “open” approach with a large abdominal incision. A laparoscope is a long, narrow telescope with a light source and video camera at the end. The scope is passed through a tiny incision into the abdomen where images from the camera are projected onto a large monitor for the surgeon to view. Laparoscopes have channels inside the scope enabling the surgeon to pass gas in and out to expand the viewing area or to insert tiny surgical instruments for treatment purposes. The surgical instruments used in operative laparoscopy are very small but appear much larger when viewed through a laparoscope.

Surgical Procedure

Nissen Fundoplication is performed as day surgery either in the hospital or outpatient surgery centres usually with the patient under general anaesthesia.

  • The surgeon uses a needle to inject a harmless gas into the abdominal cavity near the belly button to expand the viewing area of the abdomen giving the surgeon a clear view and room to work.
  • The surgeon makes a small incision in the upper abdomen and inserts a tube called a trocar through which the laparoscope is introduced into the abdomen.
  • Additional small incisions may be made for a variety of surgical instruments to be used during the procedure.
  • With the images from the laparoscope as a guide, your surgeon wraps the upper part of the stomach, the fundus, around the lower oesophagus to create a valve, suturing it in place.
  • The hole in the diaphragm through which the oesophagus passes is then tightened with sutures.
  • The laparoscope and other instruments are removed and the gas released.
  • The tiny incisions are closed and covered with small bandages.

Laparoscopy is much less traumatic to the muscles and soft tissues than the traditional method of surgically opening the abdomen with long incisions (open techniques).

Post-Operative Guidelines

After surgery, your surgeon will give you guidelines to follow.

Common post-operative guidelines following laparoscopy include the following:

  • You will need someone to drive you home after you are released as the anaesthesia may make you feel groggy and tired.
  • Do not remove the dressings over the incisions for the first two days and keep the area clean and dry. No showering or bathing during this time. The incisions usually heal in about 5 days.
  • Your surgeon may give you diet and activity restrictions. It is very important that you follow your surgeon’s instructions for a successful recovery.
  • You may feel soreness around the incision areas. Your surgeon may give you a prescription pain medicine or recommend NSAID’s (non-steroidal anti-inflammatory drugs) for the first few days to keep you comfortable.
  • If the abdomen was distended with gas, you may experience discomfort in the abdomen, chest, or shoulder area for a couple of days while the excess gas is being absorbed.
  • Contact your doctor immediately if you have a fever, chills, increased pain, bleeding or fluid leakage from the incisions, chest pain, and shortness of breath, leg pain, or dizziness.

Risks & Complications

  • As with any surgery there are potential risks involved. The decision to proceed with the surgery is made because the advantages of surgery outweigh the potential disadvantages.
  • It is important that you are informed of these risks before the surgery takes place.

Most patients do not have complications after Nissen Fundoplication; however complications can occur and depend on which type of surgery your doctor performs as well as the patient’s health status. (i.e. obese, diabetic, smoker, etc.)

Complications can be medical (general) or specific to Nissen Fundoplication.

Medical complications include those of the anaesthesia and your general wellbeing. Almost any medical condition can occur so this list is not complete. Complications include:

  • Allergic reaction to medications
  • Blood loss requiring transfusion with its low risk of disease transmission
  • Heart attack, strokes, kidney failure, pneumonia, bladder infections
  • Complications from nerve blocks such as infection or nerve damage
  • Serious medical problems can lead to ongoing health concerns, prolonged hospitalization, or rarely death.

Because the abdominal muscles are not cut in laparoscopic surgery, the pain and complications associated with abdominal surgery are lessened. However, complications can occur with any surgery. Your surgeon feels that you should be aware of complications that may take place so that your decision to proceed with this operation is taken with all relevant information available to you.

Specific complications for Nissen Fundoplication include:

  • Post-operative fever and infection: Antibiotics given at the time of surgery lessen this risk but symptoms of infection should be reported to your physician and can include fever, chills, increasing pain, bleeding, and foul smelling drainage.
  • Surgical injury to blood vessels: A rare complication that is usually recognised during surgery and repaired. Rarely, a blood transfusion may be necessary.
  • Surgical injury to stomach or oesophagus: Also a rare complication that is usually recognised during surgery and repaired.
  • Swallowing difficulties: If the new valve is too tight, swallowing can be difficult and may require dilation to loosen the valve.
  • Gas embolism: If gas is used to distend the abdominal cavity for better viewing there is a risk of gas embolism or gas bubbles in the bloodstream. This is a serious condition that can impede blood flow to vital organs or cause a blood clot to occur in a blood vessel.
  • Adhesions: Extensive scar tissue formation can form in the surgical area. Rarely, adhesions can obstruct the valve opening requiring additional surgery.
  • Conversion to Laparotomy: There are occasions when a laparoscopy cannot be completed successfully without converting to a traditional “open” surgery called a laparotomy. A laparotomy is similar but is done through a larger abdominal incision.
  • Repeat Surgery: Sometimes the new valve weakens or loosens months or years after the surgery causing symptoms again. If symptoms are severe, the surgery may need to be repeated.

Risk factors that can negatively affect adequate healing after surgery include:

  • Poor nutrition
  • Smoking
  • Obesity
  • Age (over 60)
  • Alcoholism
  • Chronic Illness
  • Steroid Use

A good knowledge of this procedure will make the stress of undertaking the procedure easier for you to bear. The decision to proceed with the procedure is made because the advantages of the procedure outweigh the potential disadvantages. It is important that you are informed of these risks before the procedure.

Although every effort is made to educate you on Nissen Fundoplication and take control, there will be specific information that will not be discussed. Talk to your doctor or health care provider about any concerns you have about this surgery.

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