What is a Nissen Fundoplication and the Connection With WLS?
January 16, 2019Gastroesophageal reflux disease (GERD) is prevalent in North America. 1 in 5 people will complain of GERD/heartburn symptoms this number increases in the people who are obese.
People describe a burning sensation deep to the sternum, acidic sensation in the mouth, foul-smelling breath, teeth decay/destruction, voice hoarseness, coughing/vomiting blood, weight loss, and other complaints. Given the variety of symptoms presented, it is very important to see a specialist to evaluate and work up these symptoms.
What is GERD/Heartburn?
Let’s start with exploring what causes GERD. The human digestive system is a complex and beautifully integrated, each organ has a duty and responsibility. This is very similar to an assembly line in a power station because the ultimate job of the digestive system is to absorb useful nutrients and discard unwanted waste.
The mouth is responsible for chewing the food and the esophagus moves it to the stomach where further digestion occurs. The junction between the stomach and the esophagus is called gastroesophageal sphincter, essentially it’s a valve which allows for food to move from the esophagus into the stomach but prevents it from regurgitating into the esophagus. This valve is elegantly constructed as it will allow for gasses (belching), to prevent the uncomfortable sensation of bloatedness, but will stop undigested food from regurgitating back into the mouth.
Back to our question of why do we care if too much acid is regurgitated back into the esophagus? As we discussed earlier, the stomach and the esophagus have two distinct roles. The stomach produces acidic juices to further digest food and therefore it’s inner lining is made to deal with these harsh conditions. However, the esophagus is not able to handle acidic juices very well. Hence, the burning sensation we feel when acid propelled from the stomach into the esophagus. The increasing acid will burn the inner lining of the esophagus. Having said that, a small amount of acid regurgitation is normal and esophagus can simply wash that back into the stomach.
It’s longstanding exposure of the esophagus to the gastric acid which can lead to changes in the esophageal lining and eventually lead to cancer of the esophagus.
Malignancy is the main reason why clinicians are very concerned about longstanding GERD. This transformation of normal esophageal lining to cancerous tumors takes many years to occur, this means we need to be vigilant because if we can stop this process early on we will be able to stop one of the deadliest malignancies we have.
Treatment Options for GERD
Medical treatments in the form of acid-suppression have been used for a long time. A class of medications known as proton-pump inhibitors (PPIs, such as omeprazole, lansoprazole, esomeprazole, only to name a few) are very effective in suppressing the acid produced by the stomach and help control symptoms significantly.
However, some concerns about the long-term use of these medications are giving us pause and reflect other treatment options. I have to say that many fear-mongering scenarios pertaining to the risk profile of these meds have been thoroughly researched and are debunked. These medications have revolutionized our management of GERD. But, one should be careful when using these medications for a long period of time which translates to months and years.
Nissen Fundoplication for GERD
Nissen fundoplication is a surgical procedure where the upper stomach is wrapped around the lower part of the esophagus. In most patients with GERD, the lower valve which we discussed earlier, is malfunctioning. Therefore, by wrapping the stomach around the lower part of the esophagus a new valve is created, mimicking the action of the malfunctioning valve.
Most patients also have a concomitant hiatal hernia that is repaired at the same time. The esophagus makes its way from the mouth through the chest into the abdomen. It must pass through a small opening in the diaphragm, the muscle separating the abdominal content from the chest organs and, is responsible for breathing. For various reasons, this opening can become large which will allow the stomach to migrate into the chest. Should this occur, it will contribute to GERD. This enlargement and migration of the stomach is known as a hiatal hernia.
Surgical treatment options have proven safe and durable treatment for GERD. Nissen Fundoplication may not be a good option for all patients, however, seeing a surgeon who specializes in this field will guide treatment options.
Nissen fundoplication is performed laparoscopically or robotically nowadays, with excellent results and minimal discomfort. Patients spend one night in the hospital and they are back to performing regular activities within a few days of the procedure.
Generally speaking, patients who have a BMI less than 35, have responded well to PPIs and would like an alternative to taking these medications in the long-run. This group of patients responds best to fundoplication.
BMI greater than 35 and GERD
If your BMI is >35 and you have GERD then you will be better served by having weight loss surgery (WLS). WLS will address both GERD and the acid reflux associated with it as well as helping the patient to lose weight.
In this instance, a Roux-En-Y gastric bypass rather than a Nissen fundoplication is a better procedure. WLS will address two major contributing issues; GERD and obesity. Obesity is a major contributing factor to increasing GERD therefore if it’s not addressed the chances of Nissen fundoplication is significant and most experts advise against performing a Nissen fundoplication in obese patients.
If you've had a Nissen Fundoplication in the past, having WLS will be a challenging case, WLS is certainly a viable option. You must see an expert bariatric surgeon who will evaluate your case and decide on the best approach for you. We have performed multiple weight loss surgery procedures on patients with prior Nissen fundoplication with successful results.
 | ABOUT THE AUTHOR Dr. Husain Abbas of Memorial Advanced Surgery, is a Board Certified surgeon trained in Minimally Invasive Surgery. After his surgical residency at St. Mary's, a Yale University affiliated hospital, Dr. Abbas completed a fellowship in Minimally Invasive Gastroesophageal & Bariatric Surgery at the University of Florida, Gainesville. Dr. Abbas' expertise extends to a wide array of gastroesophageal disorders, anti-reflux surgery, complex hernia repairs, endocrine, oncology and bariatric procedures.Read more articles from Dr. Abbas! |
