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Surgical Treatment of GERD - Nissen Fundoplication

   
RMacLean
February 2001
Last Modified January 2005
 

  
 

Also referred to as the 'wrap' or 'fundo', a surgery called the nissen fundoplication is the final option for controlling very severe GERD. Because of the possible complications that can accompany this surgery, it is typically done as a last resort.  It is by no means a cure for GERD and is only performed when severe symptoms and complications persist. It involves wrapping the upper portion of the stomach (fundus) around the lower portion of the esophagus.

There are different types of fundos performed: the Nissen fundoplication refers to wrapping the fundus all the way (360°) around the esophagus.  As well, partial wraps can be performed.  A 180° wrap is known as a Thal or Toupet fundo and a 90° wrap is known as an anterior partial wrap.

 Fundoplication surgery can be performed as an open procedure or a laparoscopic procedure. The operation is basically the same but the way the surgeon gets to the stomach and esophagus is different. A laparoscopic fundoplication means that the surgeon will use several small incisions, and special instruments, with the aid of a videoscope and TV monitors to perform the fundoplication. The recovery time from a laparoscopic fundoplication is shorter than the open procedure. There is also less post-operative pain and a less visible scar. Not all fundoplications can be done laparoscopically because of adhesions from previous operations, excessive bleeding obscuring vision, too much fatty tissue or other problems, in this case, the standard method called an open fundo would be required.  Great care should be taken in finding a surgeon capable of doing the laparoscopic method.

The patient is put under general anesthesia.  In the laparoscopic method five tiny incisions are made in the abdomen if the method being used is open, one much larger incision is made. With the laparoscopic method, one incision is used for the laparoscope and the other four are used to insert special devices with which to perform the surgery.  Many surgeons will perform a gastronomy at the time of the fundo to place a g-tube.  The decision to place the g-tube is made based on the surgeon's preferences, medical condition, the child's age and eating habits prior to surgery. Some surgeons insist on placing a g-tube when doing a fundoplication while others don't routinely place a g-tube. This will likely be in place for a few months to insist with feeding and gas bloat problems.  Some children may require the g-tube be in place longer than that.

When the fundo is completed successfully it works by keeping the lower esophageal sphincter closed enough to prevent reflux while still allowing food to pass through the esophagus and into the stomach.

Children with motility disorders don't do as well after a fundoplication as children with normal gastric motility. Children with delayed gastric emptying will sometimes have a pyloroplasty (or pylormyotomy) done when the fundoplication is done. The pyloroplasty involves cutting the pyloric muscle (the muscle at the bottom of the stomach). This allows the food to move out of the stomach faster. The pyloroplasty comes with the risk of dumping syndrome (the stomach empties too quickly) so it isn't routinely done for every child having a fundoplication.

Indications for reflux surgery

  • Esophageal stricture

  • Barrett’s esophagus (an absolute indication as this may end up in cancer )

  • Life-threatening apnea (cessation of breathing) and recurrent aspiration pneumonia

  • Large hiatal hernia

  • Failure of maximal medical therapy to reduce severe symptoms

  • Severe esophagitis (esophageal inflammation)

  • Recurrent pneumonia, chronic lung disease, bronchospasm

  • Failure to gain weight

If your child is requires surgery, learn about what to expect.

Potential Complications of the Fundoplication

Every surgery comes with risks from the anesthetic, infection and bleeding. The fundoplication surgery can have other complications as listed below.

  • Inability to burp or vomit, gas bloat syndrome (gas has to pass through the gastrointestinal tract causing gas pain and bloating....this can be severe for some children)

  • Retching (dry heaves)

  • Difficulty eating after surgery because of swelling at the fundo site or food aversion (may require tube feeds until the swelling decreases)

  • Dumping Syndrome (the stomach empties too quickly causing nausea, abdominal cramping, retching, pale skin, hypoglycemia, and sweating. Diet changes or the use of uncooked cornstarch may help alleviate the symptoms)

  • Small bowel obstruction (scar tissue adhesions form in the abdominal cavity causing parts of the small bowel to stick together)

  • Disruption of the wrap (stitches come undone and the stomach returns to 'normal' position causing the return of original problems)

  • Post-op dysphasia (swallowing problems including food getting stuck at the wrap site)

  • Hiatus hernia (the esophagus and the stomach slide up above the diaphragm and into the chest cavity)

Not all children who have a fundoplication will have these complications but many children have at least one of them.  In most cases they will improve with time.

New research indicates that most children will still experience reflux symptoms or require medical treatment after having a fundo.  According to a report in the November 2004 issue of Clinical Gastroenterology and Hepatology about two thirds of the patients in the study were seen within two months after their surgery with symptoms of reflux or received treatment for reflux.  Read more about this>

Reviewed By Dave Olson, MD
Fellow, American Academy of Pediatrics
Graduate University of Michigan School of Medicine

 


 

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