Gastroenterology Book

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Nissen FundoplicationAka: Anti-Reflux Surgery, Antireflux Surgery

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  1. Epidemiology
    1. Second most common U.S. elective surgery
      1. Gallbladder surgery is first
  2. Indications
    1. Refractory Gastroesophageal Reflux disease
      1. Failed medical therapy
      2. Persistent symptomatic esophagitis
    2. Anticipated Long-term medical therapy in young patient
    3. Esophageal bleeding
      1. Barrett's Esophagus
      2. Linear Erosions secondary to Hiatal Hernia
    4. Persistent secondary complications of regurgitation
      1. Laryngitis
      2. Asthma
  3. Contraindications (Relative)
    1. Elderly patients with significant comorbidities
    2. Significant Esophageal Dysmotility
    3. Functional symptoms at risk of worsening with surgery
    4. No available experienced anti-reflux surgeon
  4. Advantages compared with GERD Medical Therapy
    1. GERD relapses in 80% of medical treatment in 3 years
    2. Surgery in less expensive than 10 years of PPI Therapy
    3. Very safe, laparoscopic procedure
  5. Disadvantages
    1. No long-term studies confirm Nissen efficacy
    2. Laparoscopic Nissen has a steep learning curve
      1. Studies recommend first 20 procedures supervised
      2. Surgical residents before and after 25-50 procedures
        1. Comfort with procedure after 10-15 operations
        2. Complications reduced after experience
          1. Initial intra-operative complications: 20%
          2. Later intra-operative complications: 2-4%
        3. Converting laparoscopic to open procedure reduced
          1. Initial conversion to open procedure: 56%
          2. Later conversion to open procedure: 16%
  6. Complications
    1. Overall complication rate: 1-2%
    2. Conversion from laparoscopic to open procedure: <1-2%
    3. Pneumothorax: <1%
    4. Esophageal Perforation or gastric perforation: <1-2%
    5. Peri-operative mortality: <0.5%
    6. Splenic Injury or Hepatic Injury: Rare
  7. Adverse Effects
    1. New onset of gastrointestinal symptoms (67%)
      1. Dysphagia
      2. Gas
      3. Bloating
    2. Required continued antireflux drugs post-surgery (27%)
      1. Follow-up found 52% taking antacids 3-5 years post-op
      2. Lundell (2001) J Am Coll Surg 192:172
    3. Solid food Dysphagia (10%)
      1. Required esophageal dilatation after surgery (8%)
    4. Repeat surgery required (7%)
    5. References
      1. Vakil (2001) Gastroenterology :
  8. Preparatory Studies
    1. Upper Endoscopy (evaluate for Barrett's Esophagus)
    2. Upper Gastrointestinal Series (defines anatomy)
    3. Manometry
    4. 24-Hour pH Monitoring
  9. Prognosis: Best surgical candidates for best outcomes
    1. Age under 50 years
    2. Typical Gastroesophageal Reflux disease symptoms
    3. Erosive esophagitis on endoscopy
    4. Good response to Proton Pump Inhibitor
    5. Positive 24 hour pH study
    6. References
      1. Frick (2003) New Therepeutics, Cable, WI
  10. Alternative endoscopic procedures (new)
    1. Endoscopic suturing (Endo-Cinch)
    2. Stretta Procedure (Radiofrequency ablation)
    3. Experimental endoscopic procedures
      1. LES Augmentation (Microcapsule injection)
      2. Enteryx Ethylene Vinyl Alcohol Injection
  11. References
    1. Bowrey (2000) Surg Clin North Am 80(4):1213
    2. Cattey (1996) Surg Laparosc Endosc 6(6):430
    3. Feldman (1998) Sleisenger and Fordtran's, p. 509-17
    4. Frantzides (1998) 124(4):651
    5. Hinder (1997) Am J Med 103(5A):144S
    6. Horgan (1997) Surg Clin North Am 77(5):1063
    7. Laine (1997) Surg Endosc 11(5):441
    8. Lundell (2001) J Am Coll Surg 192:172
    9. Nessen (1999) JSLS 3(2):103
    10. Peters (1998) Ann Surg 228(1):40
    11. Rantanen (1999) Br J Surg 86(12):1573
    12. Soot (1999) Arch Surg 134(3):278
    13. Townsend (2001) Sabiston Surgery, Saunders, p. 755-66
    14. Watson (1996) Ann Surg 224(2):198

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