Nissen fundoplication

Nissen fundoplication

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Encyclopedia
Nissen fundoplication is a surgical procedure to treat gastroesophageal reflux disease
Gastroesophageal reflux disease
Gastroesophageal reflux disease , gastro-oesophageal reflux disease , gastric reflux disease, or acid reflux disease is chronic symptoms or mucosal damage caused by stomach acid coming up from the stomach into the esophagus...

 (GERD) and hiatus hernia
Hiatus hernia
A hiatus hernia or hiatal hernia is the protrusion of the upper part of the stomach into the thorax through a tear or weakness in the diaphragm.- Classification :There are two major kinds of hiatus hernia:...

. In GERD it is usually performed when medical therapy has failed, but with paraesophageal hiatus hernia, it is the first-line procedure. The Nissen fundoplication is total (360º), but partial fundoplications known as Belsey fundoplication (270º anterior transthoracic), Dor fundoplication (anterior 180-200º) or Toupet fundoplication (posterior 270º) are also alternative procedures with somewhat different indications.

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. In 1961 he published a more detailed overview of the procedure. Nissen originally called the surgery "gastroplication." The procedure has borne his name
Eponym
An eponym is the name of a person or thing, whether real or fictitious, after which a particular place, tribe, era, discovery, or other item is named or thought to be named...

 since it gained popularity in the 1970s.

Technique


In a fundoplication, the gastric fundus (upper part) of the stomach
Stomach
The stomach is a muscular, hollow, dilated part of the alimentary canal which functions as an important organ of the digestive tract in some animals, including vertebrates, echinoderms, insects , and molluscs. It is involved in the second phase of digestion, following mastication .The stomach is...

 is wrapped, or plicated, around the lower end of the esophagus
Esophagus
The esophagus is an organ in vertebrates which consists of a muscular tube through which food passes from the pharynx to the stomach. During swallowing, food passes from the mouth through the pharynx into the esophagus and travels via peristalsis to the stomach...

 and stitched in place, reinforcing the closing function of the lower esophageal sphincter. 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
Esophageal hiatus
In human anatomy, the esophageal hiatus is a hole in the diaphragm through which the esophagus passes. It is located in the right crus of the diaphragm.It is located approximately at level of the tenth thoracic vertebra ....

 of the diaphragm.

In a Nissen fundoplication, also called a complete fundoplication, the fundus is wrapped all the way 360 degrees around the esophagus. In contrast, surgery for achalasia
Achalasia
Achalasia , also known as esophageal achalasia, achalasia cardiae, cardiospasm, and esophageal aperistalsis, is an esophageal motility disorder involving the smooth muscle layer of the esophagus and the lower esophageal sphincter...

 is generally accompanied by either a Dor or Toupet partial fundoplication, which is less likely than a Nissen wrap to aggravate the dysphagia
Dysphagia
Dysphagia is the medical term for the symptom of difficulty in swallowing. Although classified under "symptoms and signs" in ICD-10, the term is sometimes used as a condition in its own right. Sufferers are sometimes unaware of their 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.

The procedure is now routinely performed laparoscopically
Laparoscopic surgery
Laparoscopic surgery, also called minimally invasive surgery , bandaid surgery, or keyhole surgery, is a modern surgical technique in which operations in the abdomen are performed through small incisions as opposed to the larger incisions needed in laparotomy.Keyhole surgery makes use of images...

 and robotically using the da Vinci Surgery System.
When used to alleviate gastroesophageal reflux symptoms in patients with delayed gastric emptying, it is frequently combined with modification of the pylorus
Pylorus
The pylorus is the region of the stomach that connects to the duodenum . It is divided into two parts:* the pyloric antrum, which connects to the body of the stomach.* the pyloric canal, which connects to the duodenum....

 via pyloromyotomy
Pyloromyotomy
Pyloromyotomy is a surgical procedure in which an incision is made in the longitudinal and circular muscles of the pylorus. It is used to treat hypertrophic pyloric stenosis. It is also known as Ramstedt's Operation, after Conrad Ramstedt who first performed the procedure in 1911....

 or pyloroplasty.

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
Gastric acid
Gastric acid is a digestive fluid, formed in the stomach. It has a pH of 1 to 2 and is composed of hydrochloric acid , and large quantities of potassium chloride and sodium chloride...

 (in GERD).

Complications


Nissen fundoplication is generally considered to be safe and effective, with a mortality rate of less than 1%. Studies have shown that after 10 years, 89.5% of patients are still symptom-free.

Complications include "gas bloat syndrome", dysphagia
Dysphagia
Dysphagia is the medical term for the symptom of difficulty in swallowing. Although classified under "symptoms and signs" in ICD-10, the term is sometimes used as a condition in its own right. Sufferers are sometimes unaware of their dysphagia....

 (trouble swallowing), dumping syndrome, excessive scarring, and rarely, achalasia
Achalasia
Achalasia , also known as esophageal achalasia, achalasia cardiae, cardiospasm, and esophageal aperistalsis, is an esophageal motility disorder involving the smooth muscle layer of the esophagus and the lower esophageal sphincter...

. 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
Marlex
Marlex is a trademarked name for crystalline polypropylene and high-density polyethylene . These plastics were invented by J. Paul Hogan and Robert Banks, two research chemists at the Phillips Petroleum company....

 or another form of artificial mesh to strengthen the connection. Postoperative irritable bowel syndrome, which lasts for roughly 2 weeks, is possible.

In "gas bloat syndrome", patients report being unable to belch, leading to an accumulation of gas in the stomach
Stomach
The stomach is a muscular, hollow, dilated part of the alimentary canal which functions as an important organ of the digestive tract in some animals, including vertebrates, echinoderms, insects , and molluscs. It is involved in the second phase of digestion, following mastication .The stomach is...

 or small intestine. This is said to occur in 2-5% of patients, depending on surgical technique, and is commonly believed to be related to the tightness of the "wrap". Most often, gas bloat syndrome is self-limiting within 2 to 4 weeks, but in some it may persist. The offending gas may come from dietary sources, especially carbonated beverages; another suspected cause is involuntary swallowing of air (aerophagia
Aerophagia
Aerophagia is a condition that occurs when a person swallows too much air, which goes to the stomach. It causes abdominal bloating and frequent belching and may cause pain.-Causes:...

). If gas bloat syndrome occurs postoperatively and does not resolve with time, dietary restrictions, and counselling regarding aerophagia, it may be beneficial to consider treating the condition with an endoscopic balloon dilatation
Esophageal dilatation
Esophageal dilatation is a therapeutic endoscopic procedure that enlarges the lumen of the esophagus.-Indications:It can be used to treat a number of medical conditions that result in narrowing of the esophageal lumen, or decrease motility in the distal esophagus...

.

During a laparoscopic Nissen fundoplication the operable area is inflated with gas to make the operation easier, which puts pressure on gastrointestinal organs, inhibiting their correct function. This, in conjunction with psychological and physical trauma from the operation, results in "post operative irritable bowel syndrome". The symptoms are usually initial constipation (due to recent paralysis of the muscles controlling peristalsis because of the use of anesthetics such as Propofol), remaining air, and trauma. Once the fecal matter is expelled, rapid onset diarrhea and gas expulsion is expected. Diverticulitis may occur if more fibrous material are consumed (such as porridge oats). Constipation will occur if too much fiber is eaten, which can last from 1 – 3 days, with lower frontal cramping.

Vomiting is often difficult or even impossible with a fundoplication. In some cases, the purpose of this operation is to correct excessive vomiting. However, when its purpose is to reduce gastric reflux, difficulty in vomiting may be an undesired outcome. 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.