NISSEN FUNDOPLICATION

The “gold standard” to which all anti-reflux procedures are compared is the laparoscopic Nissen fundoplication (Nissen). This minimally invasive surgical procedure is performed under general anesthesia via several small incisions. A slender scope (laparoscope) is inserted into the abdomen that produces a high-resolution image on a monitor which the surgeon carefully observes as he performs the procedure. The procedure involves repairing the hiatal hernia (typically present) and recreates a functional valve by wrapping part of the stomach around the lower esophagus at the site of the LES. The procedure takes approximately 1-2 hours with an overnight stay in the hospital. Most people are back to light, “every day” activity within a week. A successful laparoscopic Nissen fundoplication stops the reflux approximately 80-85% of the time and typically 90% of all patients are satisfied with the procedure after 5 years. Side effects can include excess gas and bloating, as well as the inability to belch or vomit. The Nissen stops the reflux with a reliability above all other existing therapies.

Common side effects from a laparoscopic Nissen fundoplication:

I’m considering surgery for my acid reflux, but I’ve heard the side effects from the Nissen fundoplication can be bothersome. What should I expect if I have the surgery?

Considering surgery can be scary.  What’s the procedure like? Will it work? Will there be any complications? Side effects? For people with chronic GERD, surgery is often considered the last resort, only an option when medical therapy has failed. But for the right patients, surgery can be an effective treatment for GERD. In their latest guidelines for the management of GERD released earlier this year (2013), the American College of Gastroenterology stated:

  • Surgical therapy is a treatment option for long-term therapy in GERD patients. (Strong recommendation, high level of evidence)
  • Surgical therapy is as effective as medical therapy for carefully selected patients with chronic GERD when performed by an experienced surgeon. (Strong recommendation, high level of evidence)

Is surgical therapy effective?

The consensus among knowledgeable GERD physicians, both medical and surgical, is that surgical therapy is very effective under the proper circumstances.  It is the only method by which reflux can be cured. Remember that therapy with acid suppressing medications (PPIs) simply relieves symptoms by reducing the amount of acid produced in the stomach. It does not stop reflux from happening. Surgery recreates the anatomic barrier between the stomach and esophagus (the LES), which stops the reflux in most cases.

What are the risks of such an apparently effective therapy?

Even though the procedure is minimally invasive with small incisions, the Nissen fundoplication is an operation.  This alone is always a concern. What then is the likelihood of adverse events during/after the surgery?

During Surgery

During the procedure, there are two main concerns:

  • Bleeding requiring transfusion,
  • Injury abdominal organs, specifically injury to the spleen requiring its removal.

The total risk for these events during the surgery is approximately 2%.

Immediately Following Surgery

Immediately following the surgery many patients have flatulence (gas), dysphagia (difficulty swallowing), and bloating.  For this reason, diet immediately following the surgery is restricted to soft foods to allow these to resolve.

Longer-Term Side Effects

Many studies have looked at longer-term side effects (defined as more than 1 month after surgery).   The results vary somewhat, but swallowing trouble persists in about 3%, diarrhea and bloating in 10%, and the inability to belch or vomit in about one-third of patients.

These side effects are very important to understand since they must be balanced against the surgical results relative to resolving GERD.

Risks vs. Benefits

One way to really assess the benefits vs. side effects is to ask those who have undergone the procedure.  Interestingly, many studies have been done looking at the frequency of these side effects themselves, but few have looked into the question “Given any side effects you may have, are you satisfied with your surgical result and would you do it over again?” In two major studies that asked these specific questions, 85%-90% answered yes.  These questions were asked 5-10 years following the surgery.

How to get the best results

If surgery is considered, how do you minimize the chances of adverse side effects?  How do you maximize chances of a good result?

The answer is to seek treatment from an experienced individual or team of physicians with specific GERD expertise. Experienced physicians will conduct a thorough evaluation to determine if surgery is a good option for you. Surgery isn’t the right option for everyone, and we can identify who is a good “candidate” and who is not! In addition, look for a surgeon who does Nissen fundoplications frequently – a good number to focus on is at least 20 per year.

Dr. Joel Richter, gastroenterologist and one of the most prominent GERD authorities in the world,  summarizes the components of getting a good result with minimal side effects in an insightful editorial:

“Successful laparoscopic antireflux surgery (Nissen fundoplication) is based on the reliability of esophageal function tests and their critical evaluation and are just as important as surgical expertise and hospital volume.”

Surgery is always a difficult decision. Antireflux surgery can have great benefits, but there are potentially undesirable side effects.  Ask people who have had the surgery what it is like. Find out if they are satisfied.  Be sure you have selected an experienced surgeon.  Do not hesitate to ask how often he or she performs antireflux surgery, and be sure a full and complete pre-surgical evaluation has been completed and interpreted by experienced individual(s).