Acid Reflux -
Laparoscopic Nissen Fundoplication
Laparoscopic Nissen Fundoplication is the usual operation for controlling severe reflux symptoms that are refractory to medical treatment and anti-reflux measures. There are other anti-reflux operations but this one is the best to control the reflux. Acid reflux is commonly associated with hiatus hernia; whether diagnosed endoscopically, radiologically or operatively.
Reflux symptoms can affect anyone occasionally, but sometimes it becomes a recurrent or persistent problem that needs treatment. Reflux occurs when the stomach acid contents flows back into the gullet, which causes irritation to the lining layer. Most common reflux symptoms include: acidity, heartburn, regurgitation (feeling of fluid or food at the back of the throat), epigastric and retrosternal pain. Non-classical symptoms include respiratory symptoms (cough, asthma attacks, shortness of breath, recurrent chest infection), teeth problems (staining especially affecting the back teeth), upper gastrointestinal bleeding (vomiting blood or passing black stool), taste changes, and dysphagia (difficult swallowing). These symptoms could occur at any time but are particularly worse following meals and on lying down, sometimes waking the patient from sleep.
Clinically; symptoms and signs
Endoscopy (camera examination of the gullet, stomach and duodenum) - OGD
24hr pH monitoring
Conservative / Medical therapy: Anti-reflux measures are able to control symptoms along with medication in over 80% of patients. These measures include avoiding late meals - nil by mouth for 2 hours before bed time, raising the head of the bed, avoiding spicy food and caffeine, stop smoking and drinking alcohol, reduce weight and eating little and often to avoid stomach overfill.
Pro-kinetics; medications that increase the motility of the gullet and stomach.
(e.g. Metoclopramide or Domperidone).
Anti-acids; medications that neutralise the acidity of the stomach (e.g. Rennies).
H2 blockers; medications that reduce the acid secretion in to the stomach (e.g. Cimetidine or Ranitidine).
Proton pump inhibitors; medications that reduce the acid secretion in to the stomach (e.g. Omeprazole, Lansoprazole, Pantoprazole or Esmoprazole).
Nissen Fundoplication (Laparoscopic / Open) - 360 degree wrap
Dor Fundoplication (Laparoscopic / Open) - 180 degree front wrap
Toupet Fundoplication (Laparoscopic / Open) - 270 degree back wrap
Lateral Fundoplication (Laparoscopic / Open) - 90 degree side wrap
Laparoscopic Nissen Fundoplication is the standard operation for reflux
symptoms. It is performed under general anaesthesia with local anaesthesia
at the site of the wounds. You will also receive intravenous antibiotics.
The operation takes an average of 2 hours and includes repair of the
diaphragm hiatus (where the gullet passes through from the chest to the
abdomen) using stitches, with/without buttressing patches. Then the upper
part of the stomach will be wrapped around the gullet in full (360 wrap).
The diagram shows the site of the wounds. You will also have an abdominal
drain from the left side and nasogastric tube [NG] (a tube inserted through
your nostril in to the stomach to decompress it).
Infection, bleeding, visceral injuries (injuries to surrounding organs), chest drain (tube inserted into the left and/or right chest if there is breach into chest lining), dysphagia (difficulty in swallowing which is usually transient (4-6 weeks) but if it lasts more than 6 months, may need intervention), adhesions, hernia, chest infection, cardiac event and venous clot in the leg (DVT), which might migrate to lung (PE). Recurrence of reflux symptoms could occur at an incidence of 5-10% in the first 10 years after surgery. You may also develop difficulty to burp or vomit since the gas within the stomach may entrap inside the wrap, this usually settles spontaneously or controlled with medication. There is also risk of conversion to open surgery (2%), which is usually an upper middle vertical incision.
You will have a general ache with backache and shoulder pain due to filling the abdomen with gas that takes 48-72hr to be absorbed. It is advisable to have your pain killers regularly for the first 5 days then tail them off.
There are no stitches to be removed, you will have glue over the wounds. You could have a shower once the abdominal drain is removed but no bath until day 5 when you can rub the glue off in the bath/shower.
You will normally have an element of dysphagia (difficulty swallowing) that usually takes up to 6 weeks to settle. You usually stay in hospital for average of 3 nights. During your hospital stay, you will be progressed gradually in the oral intake until all the tubes/drains are removed. You will be discharged from hospital after tolerating soft diet.
Before discharge from hospital you need to meet 5 conditions:
Feeling well and mobilising
Tolerating soft food and drinking without being sick (vomiting)
Normal observation (pulse, blood pressure and temperature)
Passing urine normally
Someone will stay with you overnight
You should continue on soft diet (avoid any solids), anti-acids and anti-sickness for 4-6 weeks until reviewed You should also avoid fizzy drinks for 6 months. All medications taken should be in a liquid or crushed form.
We can give you a sick note for 2-3 weeks and if you need an extra week, your doctor (GP) can provide you with this. You can walk, but be careful with stairs, always protect your larger wounds when coughing, sneezing or straining. You should avoid driving the first 10 days, and after that if you are able to control your vehicle and press emergency brake, then you can drive. Gradually increase activity back to normal over the next three weeks from surgery. Ideally, you should avoid flights, especially long distance, in the first four weeks after surgery and better to check with your flight insurer before booking.
I will review you in the clinic around 4 weeks following the surgery to assess your recovery where you will be progressed to normal diet gradually over next 2 weeks. You need to be careful on the methodology of eating: small bites, chew the food very well, make sure the food is moist (add lot of sauces), take your time with your meals (slowed pace) and eat little and often. if you have any problems you could contact my secretary or the hospital ward and I will be in touch.