User:VP0200/Nissen fundoplication

Indications

The most common indication for a fundoplication is GERD that has failed lifestyle modification and medical management. Patients that continue to have reflux symptoms or that have had uncontrolled reflux symptoms for more than 5 years are also candidates for surgical management. Complications that arise from long term GERD such as severe esophagitis, stricture formation, and ulcer development, all of which can be seen on endoscopy, warrant surgical intervention. Presence of Barrett's esophagus is not an indication, as the benefit of a fundoplication in preventing progression into adenocarcinoma is controversial. Respiratory symptoms and upper airway symptoms such as cough, asthma, hoarseness are also indications for surgical intervention. In the pediatric population, infants who fail to thrive or have inadequate weight gain despite PPI therapy may also benefit from fundoplication.

Effectiveness[edit]

Nissen (complete) fundoplication is generally considered to be safe and effective, with a mortality rate of less than 1% and many of the most common post-operative complications minimized or eliminated by the partial fundoplication procedures now more commonly used. Studies have shown that after 10 years, 89.5% of patients are still symptom-free. When compared to stand alone medical therapy with PPIs, Nissen fundoplication has been found to be superior in reducing acid reflux as well as the symptoms associated with reflux. Fundoplication was found to be better at increasing LES pressure than PPI therapy, whilst having similar risk for adverse events. In patients with non-acid reflux, a hiatal hernia, or respiratory symptoms, surgical intervention was found to be more effective at controlling symptoms than PPIs alone.

Complications[edit]

Complications include "gas bloat syndrome", dysphagia (trouble swallowing), dumping syndrome, excessive scarring, vagus nerve injury and, rarely, achalasia. The fundoplication can also come undone over time in about 5–10% of cases, leading to recurrence of symptoms. If the symptoms warrant a repeat surgery, the surgeon may use Marlex or another form of artificial mesh to strengthen the connection. Postoperative irritable bowel syndrome, which lasts for roughly 2 weeks, is possible.

In "gas bloat syndrome", fundoplication can alter the mechanical ability of the stomach to eliminate swallowed air by belching, leading to an accumulation of gas in the stomach or small intestine. Data varies, but some degree of gas-bloat may occur in as many as 41% of Nissen patients, whereas the occurrence is less with patients undergoing partial anterior fundoplication. Gas bloat syndrome is usually self-limiting within 2 to 4 weeks, but in some it may persist. The offending gas may also come from dietary sources (especially carbonated beverages), or involuntary swallowing of air (aerophagia). If postoperative gas-bloat syndrome does not resolve with time, dietary restrictions, counseling regarding aerophagia, and correction – either by endoscopic balloon dilatation^{[citation needed]} or repeat surgery to revise the Nissen fundoplication to a partial fundoplication – may be necessary.

Acute dysphagia or short term trouble swallowing is a symptom that most patients will have after having a fundoplication. Patients who have dysphagia prior to surgery are more likely to have some dysphagia post-operatively. Symptoms of dysphagia will often resolve on their own within a few months. Short term dysphagia is controlled by modifying diet to include more easily swallowed food such as liquids and soft foods. Dysphagia that persists longer than 3 months will need further evaluation, typically with a barium swallow study, esophageal manometry, or endoscopy. Structural changes such as movement of the wrap, herniation, development of stenosis or stricture may lead to persistent dysphagia. Previously undiagnosed achalasia or a wrap that is too tight may also lead to persistent dysphagia. Depending on the etiology of persistent dysphagia, a trial of PPI therapy, endoscopic dilation, or surgical revision may be necessary.

Vomiting is sometimes impossible or, if not, very painful after a fundoplication, with the likelihood of this complication typically decreasing in the months after surgery. In some cases, the purpose of this operation is to correct excessive vomiting. Initially, vomiting is impossible; however, small amounts of vomit may be produced after the wrap settles over time, and in extreme cases such as alcohol poisoning or food poisoning, the patient may be able to vomit freely with some amount of pain.