The Nissen Fundoplication for Reflux
The Nissen fundoplication is an operation that has been used to treat reflux disease for more than 60 years. It is the gold standard operation to which other reflux operations, like the TIF, will always be compared to for efficacy. Essentially, it involves wrapping the upper stomach behind the esophagus to build up the sphincter between the esophagus and stomach.
The operation may be combined with a repair of a hernia in the diaphragm where the esophagus comes out of the chest and into the abdomen. This is called a hiatal hernia. Whether the hernia is repaired or not, the 360 degree wrap of the stomach provides the anti-reflux portion of the operation. It has had great success in treating refractory reflux disease; that is, reflux that has gotten worse despite medication use. However, there are some side effects of the Nissen that must be considered before surgery. First, the function of the esophagus must be normal. That is, the esophagus must be able to push food down the esophagus forcefully enough to overcome the pressure at the wrap. Even if the wrap is made lose enough, the patient with a poorly functioning esophagus may experience dysphagia (trouble swallowing). This will cause the feeling of food getting stuck in the esophagus and is very uncomfortable. The esophageal function can be determined with a test called manometry. If the esophagus does not function well, then a TIF or partial wrap should be offered to the patient to prevent these problems.
Secondly, all patients will experience some degree of bloating. For some patients it is minor and not an issue, for others it is a very uncomfortable feeling of not being able to burp or vomit. Again, the tightness of the wrap matters. This is why most surgeons advocate an extremely lose wrap of the stomach.
Despite these two possible side effects, for patients who live with constant, severe, reflux disease, the Nissen offers a great long term solution. It is more robust than the TIF. On average, 80% patients who have a Nissen fundoplication are heartburn free and off their medications at 5 years compared to the TIF which has a very respectable 60% off medications and heartburn free at 3 years. Heartburn and reflux disease doctors should visualize the disease on a spectrum of mild, moderate, and sever and take into consideration the patient’s age and comorbid conditions when it comes to determining the right course of treatment for them. For most patients, life style changes and/or medications can be enough to help them live heartburn free. For others, this will fail and they will need some sort of mechanical repair. If their symptoms are sever, there is damage of the esophagus, or other methods have failed, surgery should be considered the next option. The Nissen fundoplication offers the most durable and robust surgical treatment for reflux disease.
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