Nissen fundoplication

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Nissen fundoplication
Nissen fundoplication.png
Diagram of a Nissen fundoplication.
Other namesLaparoscopic Nissen fundoplication
ICD-9-CM 44.66, 44.67

A Nissen fundoplication, or laparoscopic Nissen fundoplication when performed via laparoscopic surgery, is a surgical procedure to treat gastroesophageal reflux disease (GERD) and hiatal hernia. In GERD, it is usually performed when medical therapy has failed; but, with a Type II (paraesophageal) hiatus hernia, it is the first-line procedure. The Nissen fundoplication is total (360°), but partial fundoplications known as Thal (270° anterior), Belsey (270° anterior transthoracic), Dor (anterior 180–200°), Lind (300° posterior), and Toupet fundoplications (posterior 270°) are alternative procedures with somewhat different indications and outcomes. [1]

Contents

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. [2] In 1961 he published a more detailed overview of the procedure. [3] Nissen originally called the surgery "gastroplication". The procedure has borne his name since it gained popularity in the 1970s. [4]

Indications

The most common indication for a fundoplication is GERD that has failed lifestyle modification and medical management. [5] 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. [6] 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. [6] Respiratory symptoms and upper airway symptoms such as cough, asthma, hoarseness are also indications for surgical intervention. [7] In the pediatric population, infants who fail to thrive or have inadequate weight gain despite proton-pump inhibitor (PPI) therapy may also benefit from fundoplication. [8]

Technique

A completed Nissen fundoplication Watercolour of the Nissen-method.jpg
A completed Nissen fundoplication

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 (LES). 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. The surgeon should begin with ligating and dividing the short gastric arteries. [9]

In a Nissen fundoplication, also called a complete fundoplication, the fundus is wrapped the entire 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.[ citation needed ]

The procedure can be performed with open surgery but is now routinely performed laparoscopically, as laparoscopic surgery has decreased post-operative complications and decreased hospital stay. [10] 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.[ citation needed ]

This procedure can also be completed robotically. Outcomes comparing laparoscopic fundoplication to robotic fundoplication show similar clinical outcomes, but robotic fundoplication is more likely to have an increased length of operative time and financial cost. [11]

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). Although antacids and PPI drug therapy can reduce the effects of reflux acid, successful surgical treatment has the advantage of eliminating drug side-effects and damaging effects from other components of reflux such as bile or gastric contents. [1] The Nissen fundoplication reduces reflux by reinforcing the LES by increasing LES pressure and increasing the LES length. [6]

Effectiveness

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. [12] Fundoplication was found to be better at increasing LES pressure than PPI therapy, whilst having similar risk for adverse events. [13] 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. [7]

Complications

Complications include "gas bloat syndrome", dysphagia (trouble swallowing), dumping syndrome, excessive scarring, vagus nerve injury and, rarely, achalasia. [14] 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. [15] Postoperative ileus, which is common after abdominal surgery, 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. [16] 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, medications, and correction – either by endoscopic balloon dilatation [ citation needed ] or repeat surgery to revise the Nissen fundoplication to a partial fundoplication – may be necessary. [16]

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. [17] Symptoms of dysphagia will often resolve on their own within a few months. [18] Short term dysphagia is controlled by modifying diet to include more easily swallowed food such as liquids and soft foods. [19] Dysphagia that persists longer than 3 months will need further evaluation, typically with a barium swallow study, esophageal manometry, or endoscopy. [20] Structural changes such as movement of the wrap, herniation, development of stenosis or stricture may lead to persistent dysphagia. [19] Previously undiagnosed achalasia or a wrap that is too tight may also lead to persistent dysphagia. [18] Depending on the etiology of persistent dysphagia, a trial of PPI therapy, endoscopic dilation, or surgical revision may be necessary. [21]

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.

See also

Related Research Articles

<span class="mw-page-title-main">Gastroenterology</span> Branch of medicine focused on the digestive system and its disorders

Gastroenterology is the branch of medicine focused on the digestive system and its disorders. The digestive system consists of the gastrointestinal tract, sometimes referred to as the GI tract, which includes the esophagus, stomach, small intestine and large intestine as well as the accessory organs of digestion which include the pancreas, gallbladder, and liver. The digestive system functions to move material through the GI tract via peristalsis, break down that material via digestion, absorb nutrients for use throughout the body, and remove waste from the body via defecation. Physicians who specialize in the medical specialty of gastroenterology are called gastroenterologists or sometimes GI doctors. Some of the most common conditions managed by gastroenterologists include gastroesophageal reflux disease, gastrointestinal bleeding, irritable bowel syndrome, inflammatory bowel disease (IBD) which includes Crohn's disease and ulcerative colitis, peptic ulcer disease, gallbladder and biliary tract disease, hepatitis, pancreatitis, colitis, colon polyps and cancer, nutritional problems, and many more.

<span class="mw-page-title-main">Esophageal achalasia</span> Rare, incurable, progressive motility disorder due to failure of esophogeal motor neurons

Esophageal achalasia, often referred to simply as achalasia, is a failure of smooth muscle fibers to relax, which can cause the lower esophageal sphincter to remain closed. Without a modifier, "achalasia" usually refers to achalasia of the esophagus. Achalasia can happen at various points along the gastrointestinal tract; achalasia of the rectum, for instance, may occur in Hirschsprung's disease. The lower esophageal sphincter is a muscle between the esophagus and stomach that opens when food comes in. It closes to avoid stomach acids from coming back up. A fully understood cause to the disease is unknown, as are factors that increase the risk of its appearance. Suggestions of a genetically transmittable form of achalasia exist, but this is neither fully understood, nor agreed upon.

Heller myotomy is a surgical procedure in which the muscles of the cardia are cut, allowing food and liquids to pass to the stomach. It is used to treat achalasia, a disorder in which the lower esophageal sphincter fails to relax properly, making it difficult for food and liquids to reach the stomach.

An esophageal motility disorder (EMD) is any medical disorder resulting from dysfunction of the coordinated movement of esophagus, which causes dysphagia.

<span class="mw-page-title-main">Gastroesophageal reflux disease</span> Medical condition

Gastroesophageal reflux disease (GERD) or gastro-oesophageal reflux disease (GORD) is a chronic upper gastrointestinal disease in which stomach content persistently and regularly flows up into the esophagus, resulting in symptoms and/or complications. Symptoms include dental corrosion, dysphagia, heartburn, odynophagia, regurgitation, non-cardiac chest pain, extraesophageal symptoms such as chronic cough, hoarseness, reflux-induced laryngitis, or asthma. In the long term, and when not treated, complications such as esophagitis, esophageal stricture, and Barrett's esophagus may arise.

<span class="mw-page-title-main">Hiatal hernia</span> Type of hernia

A hiatal hernia or hiatus hernia is a type of hernia in which abdominal organs slip through the diaphragm into the middle compartment of the chest. This may result in gastroesophageal reflux disease (GERD) or laryngopharyngeal reflux (LPR) with symptoms such as a taste of acid in the back of the mouth or heartburn. Other symptoms may include trouble swallowing and chest pains. Complications may include iron deficiency anemia, volvulus, or bowel obstruction.

<span class="mw-page-title-main">Esophagectomy</span>

Esophagectomy or oesophagectomy is the surgical removal of all or parts of the esophagus.

<span class="mw-page-title-main">Eosinophilic esophagitis</span> Allergic inflammatory condition of the esophagus

Eosinophilic esophagitis (EoE) is an allergic inflammatory condition of the esophagus that involves eosinophils, a type of white blood cell. In healthy individuals, the esophagus is typically devoid of eosinophils. In EoE, eosinophils migrate to the esophagus in large numbers. When a trigger food is eaten, the eosinophils contribute to tissue damage and inflammation. Symptoms include swallowing difficulty, food impaction, vomiting, and heartburn.

Esophageal dysphagia is a form of dysphagia where the underlying cause arises from the body of the esophagus, lower esophageal sphincter, or cardia of the stomach, usually due to mechanical causes or motility problems.

<span class="mw-page-title-main">Laparoscopic hiatal hernia repair</span> Medical procedure

Laparoscopic hernia repair is the repair of a hiatal hernia using a laparoscope, which is a tiny telescope-like instrument. A hiatal hernia is the protrusion of an organ through its wall or cavity. There are several different methods that can be used when performing this procedure. Among them are the Nissen Fundoplication and the general laparoscopic hernia repair.

Stretta is a minimally invasive endoscopic procedure for the treatment of gastroesophageal reflux disease (GERD) that delivers radiofrequency energy in the form of electromagnetic waves through electrodes at the end of a catheter to the lower esophageal sphincter (LES) and the gastric cardia – the region of the stomach just below the LES. The energy heats the tissue, ultimately causing it to swell and stiffen; the way this works was not understood as of 2015, but it was thought that perhaps the heat causes local inflammation, collagen deposition and muscular thickening of the LES and that it may disrupt the nerves there.

<span class="mw-page-title-main">Nutcracker esophagus</span> Medical condition

Nutcracker esophagus, jackhammer esophagus, or hypercontractile peristalsis, is a disorder of the movement of the esophagus characterized by contractions in the smooth muscle of the esophagus in a normal sequence but at an excessive amplitude or duration. Nutcracker esophagus is one of several motility disorders of the esophagus, including achalasia and diffuse esophageal spasm. It causes difficulty swallowing, or dysphagia, with both solid and liquid foods, and can cause significant chest pain; it may also be asymptomatic. Nutcracker esophagus can affect people of any age but is more common in the sixth and seventh decades of life.

A Cameron lesion is a linear erosion or ulceration of the mucosal folds lining the stomach where it is constricted by the thoracic diaphragm in persons with large hiatal hernias. The lesions may cause chronic blood loss resulting in iron deficiency anemia; less often they cause acute bleeding.

<span class="mw-page-title-main">Impedance–pH monitoring</span>

Impedance–pH monitoring is a technique used in the diagnosis of gastroesophageal reflux disease (GERD), by monitoring both impedance and pH.

<span class="mw-page-title-main">Esophageal pH monitoring</span>

Esophageal pH monitoring is the current gold standard for diagnosis of gastroesophageal reflux disease (GERD). It provides direct physiologic measurement of acid in the esophagus and is the most objective method to document reflux disease, assess the severity of the disease and monitor the response of the disease to medical or surgical treatment. It can also be used in diagnosing laryngopharyngeal reflux.

<span class="mw-page-title-main">Rudolph Nissen</span> German-Swiss surgeon (1896–1981)

Rudolph Nissen was a German surgeon who chaired surgery departments in Turkey, the United States and Switzerland. The Nissen fundoplication, a surgical procedure for the treatment of gastroesophageal reflux disease, is named after him.

The per-oral endoscopic myotomy, or POEM, is a minimally invasive surgical procedure for the treatment of achalasia wherein the inner circular muscle layer of the lower esophageal sphincter is divided through a submucosal tunnel. This enables food and liquids to pass into the stomach, a process that is impaired in achalasia. The tunnel is created, and the myotomy performed, using a flexible endoscope, meaning the entire procedure can be done without external incisions.

Transoral incisionless fundoplication (TIF) is an endoscope treatment designed to relieve symptoms of gastroesophageal reflux disease (GERD). The TIF procedure, similar to Nissen fundoplication, alleviates GERD symptoms by wrapping a portion of the stomach around the esophagus.

<span class="mw-page-title-main">Acid peptic diseases</span> Overview of the acid peptic diseases of the stomach and gastrointestinal tract

Acid peptic diseases, such as peptic ulcers, Zollinger-Ellison syndrome, and gastroesophageal reflux disease, are caused by distinct but overlapping pathogenic mechanisms involving acid effects on mucosal defense. Acid reflux damages the esophageal mucosa and may also cause laryngeal tissue injury, leading to the development of pulmonary symptoms.

Esophagogastric junction outflow obstruction (EGJOO) is an esophageal motility disorder characterized by increased pressure where the esophagus connects to the stomach at the lower esophageal sphincter. EGJOO is diagnosed by esophageal manometry. However, EGJOO has a variety of etiologies; evaluating the cause of obstruction with additional testing, such as upper endoscopy, computed tomography, or endoscopic ultrasound may be necessary. When possible, treatment of EGJOO should be directed at the cause of obstruction. When no cause for obstruction is found, observation alone may be considered if symptoms are minimal. Functional EGJOO with significant or refractory symptoms may be treated with pneumatic dilation, per-oral endoscopic myotomy (POEM), or botulinum toxin injection.

References

  1. 1 2 Minjarez, Renee C.; Jobe, Blair A. (16 May 2006). "Surgical therapy for gastroesophageal reflux disease". GI Motility Online. doi:10.1038/gimo56 (inactive 31 January 2024).{{cite journal}}: CS1 maint: DOI inactive as of January 2024 (link)
  2. ↑ Nissen R (1956). "Eine einfache Operation zur Beeinflussung der Refluxösophagitis" [A Simple Operation for Control of Reflux Esophagitis]. Schweizerische Medizinische Wochenschrift (in German). 86 (Suppl 20): 590–592. PMID   13337262. NAID   10008497300.
  3. ↑ 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. S2CID   29470586.
  4. ↑ Stylopoulos N, Rattner DW; Rattner (2005). "The History of Hiatal Hernia surgery: From Bowditch to Laparoscopy". Ann. Surg. 241 (1): 185–93. doi:10.1097/01.sla.0000149430.83220.7f. PMC   1356862 . PMID   15622007.
  5. ↑ Frazzoni, Marzio (2014). "Laparoscopic fundoplication for gastroesophageal reflux disease". World Journal of Gastroenterology. 20 (39): 14272–14279. doi: 10.3748/wjg.v20.i39.14272 . ISSN   1007-9327. PMC   4202356 . PMID   25339814.
  6. 1 2 3 Wykypiel, H.; Wetscher, G. J.; Klingler, P.; Glaser, K. (November 2005). "The Nissen fundoplication: indication, technical aspects and postoperative outcome". Langenbeck's Archives of Surgery. 390 (6): 495–502. doi:10.1007/s00423-004-0494-7. ISSN   1435-2443. PMID   15351884. S2CID   278325.
  7. 1 2 Patti, Marco G. (2016-01-01). "An Evidence-Based Approach to the Treatment of Gastroesophageal Reflux Disease". JAMA Surgery. 151 (1): 73–78. doi:10.1001/jamasurg.2015.4233. ISSN   2168-6254. PMID   26629969.
  8. ↑ Slater, Bethany J.; Rothenberg, Steven S. (December 2017). "Fundoplication". Clinics in Perinatology. 44 (4): 795–803. doi:10.1016/j.clp.2017.08.009. PMID   29127961. S2CID   242477061.
  9. ↑ Holcomb GW 3rd, St Peter SD (2019). "Error traps and safety steps when performing a laparoscopic Nissen fundoplication". Semin Pediatr Surg. 28 (3): 160–163. doi:10.1053/j.sempedsurg.2019.04.019. PMID   31171151. S2CID   150096013.
  10. ↑ Eshraghi, Niknam; Farahmand, Mehrdad; Soot, Scott J.; Rand-Luby, Leslie; Deveney, Clifford W.; Sheppard, Brett C. (May 1998). "Comparison of outcomes of open versus laparoscopic nissen fundoplication performed in a single practice". The American Journal of Surgery. 175 (5): 371–374. doi:10.1016/s0002-9610(98)00049-x. ISSN   0002-9610. PMID   9600280.
  11. ↑ Markar, S. R.; Karthikesalingam, A. P.; Hagen, M. E.; Talamini, M.; Horgan, S.; Wagner, O. J. (2010). "Robotic vs. laparoscopic Nissen fundoplication for gastro-oesophageal reflux disease: systematic review and meta-analysis". The International Journal of Medical Robotics and Computer Assisted Surgery. 6 (2): 125–131. doi:10.1002/rcs.309. PMID   20506440. S2CID   23663135.
  12. ↑ Richter, Joel E.; Kumar, Ambuj; Lipka, Seth; Miladinovic, Branko; Velanovich, Vic (April 2018). "Efficacy of Laparoscopic Nissen Fundoplication vs Transoral Incisionless Fundoplication or Proton Pump Inhibitors in Patients With Gastroesophageal Reflux Disease: A Systematic Review and Network Meta-analysis". Gastroenterology. 154 (5): 1298–1308.e7. doi:10.1053/j.gastro.2017.12.021. ISSN   1528-0012. PMID   29305934.
  13. ↑ Tristão, Luca Schiliró; Tustumi, Francisco; Tavares, Guilherme; Bernardo, Wanderley Marques (April 2021). "Fundoplication versus oral proton pump inhibitors for gastroesophageal reflux disease: a systematic review and meta-analysis of randomized clinical trials". Esophagus. 18 (2): 173–180. doi:10.1007/s10388-020-00806-w. ISSN   1612-9067. PMID   33527310. S2CID   231746674.
  14. ↑ 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.
  15. ↑ Curet MJ, Josloff RK, Schoeb O, Zucker KA; Josloff; Schoeb; Zucker (1999). "Laparoscopic reoperation for failed antireflux procedures". Archives of Surgery. 134 (5): 559–63. doi: 10.1001/archsurg.134.5.559 . PMID   10323431.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  16. 1 2 Booth, M.I. (2003). "Treatments: What Is the Current Rate of Gas-Bloat Syndrome Following Open and Laparoscopic Antireflux Surgery?". In Giuli, R.; Siewert, J.R; Couturier, D.; Scarpignato, C. (eds.). Barrett's Esophagus. Vol. 6. OESO, UNESCO.
  17. ↑ Herron, D. M.; Swanström, L. L.; Ramzi, N.; Hansen, P. D. (December 1999). "Factors predictive of dysphagia after laparoscopic Nissen fundoplication". Surgical Endoscopy. 13 (12): 1180–1183. doi:10.1007/PL00009616. ISSN   0930-2794. PMID   10594261. S2CID   20831084.
  18. 1 2 Wo, J. M.; Trus, T. L.; Richardson, W. S.; Hunter, J. G.; Branum, G. D.; Mauren, S. J.; Waring, J. P. (November 1996). "Evaluation and management of postfundoplication dysphagia". The American Journal of Gastroenterology. 91 (11): 2318–2322. ISSN   0002-9270. PMID   8931410.
  19. 1 2 Yadlapati, Rena; Hungness, Eric S.; Pandolfino, John E. (August 2018). "Complications of Antireflux Surgery". The American Journal of Gastroenterology. 113 (8): 1137–1147. doi:10.1038/s41395-018-0115-7. ISSN   1572-0241. PMC   6394217 . PMID   29899438.
  20. ↑ Richter, Joel E. (May 2013). "Gastroesophageal Reflux Disease Treatment: Side Effects and Complications of Fundoplication". Clinical Gastroenterology and Hepatology. 11 (5): 465–471. doi: 10.1016/j.cgh.2012.12.006 . PMID   23267868.
  21. ↑ Spechler, Stuart Jon (March 2004). "The Management of Patients Who Have "Failed" Antireflux Surgery". American Journal of Gastroenterology. 99 (3): 552–561. doi:10.1111/j.1572-0241.2004.04081.x. ISSN   0002-9270. PMID   15056101. S2CID   6795623.
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