Nissen fundoplication

Nissen fundoplication
Intervention
Diagram of a Nissen fundoplication.
ICD-9-CM	44.66, 44.67

Nissen fundoplication is a surgical procedure to treat gastroesophageal reflux disease (GERD) and hiatus hernia. In GERD it is usually performed when medical therapy has failed, but with paraesophageal hiatus hernia, it is the first-line procedure. The Nissen fundoplication is total (360º), but partial fundoplications known as Belsey fundoplication (270º anterior transthoracic), Dor fundoplication (anterior 180-200º) or Toupet fundoplication (posterior 270º) are also alternative procedures with somewhat different indications.

History

Dr. Rudolph Nissen (1896–1981) first performed the procedure in 1955 and published the results of two cases in a 1956 Swiss Medical Weekly.^[1] In 1961 he published a more detailed overview of the procedure.^[2] Nissen originally called the surgery "gastroplication." The procedure has borne his name since it gained popularity in the 1970s.^[3]

Technique

In a fundoplication, the gastric fundus (upper part) of the stomach is wrapped, or plicated, around the lower end of the esophagus and stitched in place, reinforcing the closing function of the lower esophageal sphincter. The esophageal hiatus is also narrowed down by sutures to prevent or treat concurrent hiatal hernia, in which the fundus slides up through the enlarged esophageal hiatus of the diaphragm.

In a Nissen fundoplication, also called a complete fundoplication, the fundus is wrapped all the way 360 degrees around the esophagus. In contrast, surgery for achalasia is generally accompanied by either a Dor or Toupet partial fundoplication, which is less likely than a Nissen wrap to aggravate the dysphagia that characterizes achalasia. In a Dor (anterior) fundoplication, the fundus is laid over the top of the esophagus; while in a Toupet (posterior) fundoplication, the fundus is wrapped around the back of the esophagus.

The procedure is now routinely performed laparoscopically and robotically using the da Vinci Surgery System. When used to alleviate gastroesophageal reflux symptoms in patients with delayed gastric emptying, it is frequently combined with modification of the pylorus via pyloromyotomy or pyloroplasty.

Mechanism of relief

Whenever the stomach contracts, it also closes off the esophagus instead of squeezing stomach acids into it. This prevents the reflux of gastric acid (in GERD).

Complications

Nissen fundoplication is generally considered to be safe and effective, with a mortality rate of less than 1%. Studies have shown that after 10 years, 89.5% of patients are still symptom-free.^[4]

Complications include "gas bloat syndrome", dysphagia (trouble swallowing), dumping syndrome, excessive scarring, and rarely, achalasia.^[5] 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.^[6] Postoperative irritable bowel syndrome, which lasts for roughly 2 weeks, is possible.

In "gas bloat syndrome", patients report being unable to belch, leading to an accumulation of gas in the stomach or small intestine. This is said to occur in 2-5% of patients, depending on surgical technique, and is commonly believed to be related to the tightness of the "wrap". Most often, gas bloat syndrome is self-limiting within 2 to 4 weeks, but in some it may persist. The offending gas may come from dietary sources, especially carbonated beverages; another suspected cause is involuntary swallowing of air (aerophagia). If gas bloat syndrome occurs postoperatively and does not resolve with time, dietary restrictions, and counselling regarding aerophagia, it may be beneficial to consider treating the condition with an endoscopic balloon dilatation.^{[citation needed]}

During a laparoscopic Nissen fundoplication the operable area is inflated with gas to make the operation easier, which puts pressure on gastrointestinal organs, inhibiting their correct function. This, in conjunction with psychological and physical trauma from the operation, results in "post operative irritable bowel syndrome". The symptoms are usually initial constipation (due to recent paralysis of the muscles controlling peristalsis because of the use of anesthetics such as Propofol), remaining air, and trauma. Once the fecal matter is expelled, rapid onset diarrhea and gas expulsion is expected. Diverticulitis may occur if more fibrous material are consumed (such as porridge oats). Constipation will occur if too much fiber is eaten, which can last from 1 – 3 days, with lower frontal cramping.

Vomiting is often difficult or even impossible with a fundoplication. In some cases, the purpose of this operation is to correct excessive vomiting. However, when its purpose is to reduce gastric reflux, difficulty in vomiting may be an undesired outcome. 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.

References

1. ^ Nissen R (1956). "[A simple operation for control of reflux esophagitis.]" (in German). Schweizerische medizinische Wochenschrift 86 (Suppl 20): 590–2. PMID 13337262. 
2. ^ Nissen R (1961). "Gastropexy and "fundoplication" in surgical treatment of hiatal hernia". The American journal of digestive diseases 6 (10): 954–61. doi:10.1007/BF02231426. PMID 14480031. 
3. ^ Stylopoulos N, Rattner DW (2005). "The history of hiatal hernia surgery: from Bowditch to laparoscopy". Ann. Surg. 241 (1): 185–93. PMC 1356862. PMID 15622007. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=1356862. 
4. ^ Minjarez, RC; Jobe BA. "Surgical therapy for gastroesophageal reflux disease". GI Motility online. doi:10.1038/gimo56 (inactive 2008-06-21). http://www.nature.com/gimo/contents/pt1/full/gimo56.html. 
5. ^ Waring JP (1999). "Postfundoplication complications. Prevention and management". Gastroenterol. Clin. North Am. 28 (4): 1007–19, viii–ix. doi:10.1016/S0889-8553(05)70102-3. PMID 10695014. 
6. ^ Curet MJ, Josloff RK, Schoeb O, Zucker KA (1999). "Laparoscopic reoperation for failed antireflux procedures". Archives of surgery 134 (5): 559–63. doi:10.1001/archsurg.134.5.559. PMID 10323431.