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Nissen Fundoplication

 Antireflux Surgery For GERD

Various surgical procedures have been developed since the early reports by Dr. Rudolf Nissen in the mid 50's about the fundoplication that he described for people with severe gastroesophageal reflux. Surgery was seen a last resort and when it was first performed was accompanied by frequent problems with patients unable to burp or vomit. This could lead to episodes of severe pain that required insertion of a special tube to decompress the stomach (naso-gastric tube). This so called "gas bloat syndrome" was a nuisance and effected the reputation of this operation. In the 70's and 80's, the "floppy Nissen" fundoplication was devised that enabled the patient to burp and vomit. This meant that the operation was much more acceptable.

In the early 90's, surgery underwent a revolution with the advent of laparoscopic cholecystectomy (removal of the gallbladder). As surgeons grew in their facility with the laparoscopic/videoscopic technique, they began adapting open operations to the videoscopic mode. One such operation first performed in Belgium was the laparoscopic Nissen fundoplication. Pictured above is the stomach wrapped around the distal esophagus. This effectively creates a valve that prevents stomach juices from running back up into the esophagus and burning the tender lining of the esophagus.

The operation is performed with the patient lying flat and asleep with a tube in to breathe for the patient. The videoscope is passed into the abdomen and carbon dioxide gas inflates the abdomen enabling the surgeon to see. Four other ports are placed in the upper abdomen through which the surgeon creates a tunnel behind the esophagus and through which he pulls the stomach around the esophagus to create the wrap.

The stomach is sewn in place usually calibrating the size of the wrap with a dilator that is passed through the esophagus. If there is a hole in the esophageal hiatus, this may be closed with sutures placed to make this hole smaller.

Following the operation, the patient is started on liquids for a short time and then is advanced to a soft diet for a couple of weeks. They may then resume a solid diet. The goal of this operation is to have the patient off medications for heartburn and allow them to sleep flat and eat later in the evening.

The risks of this operation include ( but are not limited to ) esophageal perforation when the dilator is passed and when the esophageal tunnel is created, splenic bleeding possibly requiring open splenectomy to correct, gastric or intestinal perforation, and wrap failure.

For people with severe reflux disease, this operation offers the opportunity for a return to some normalcy to their lifestyle. Improvement in hoarseness, breathing, absence of heartburn and sour reflux, ability to sleep flat and eat late are all goals of successful surgery.

Informed Consent: This procedure carries the usual risk of general anesthesia which varies depending upon age and other medical conditions that may make anesthesia more risky ( eg severe lung disease). Those risks that are particular to this procedure involve perforation of the GI tract (by an esophageal dilator during the operation, during the dissection of the esophagus to perform the wrap, or due to a laparoscopic instrument perforating a part of the GI tract). During the dissection of the stomach, the spleen can bleed and require the operation to be completed in an open rather than laparoscopic fashion and could mean that the spleen would need to be removed. The long term consequences of the operation may include difficulty swallowing, recurrent reflux, wrap failure, incisonal hernias, adhesions, and nonspecific discomfort when swallowing. Finally, as the risk in any major abdominal operation is always present that the patient could die from the operation.


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