by Karen Schroeder, MS, RD, MEd
Anatomy and Physiology
Digestion begins in the mouth. As teeth break food into smaller pieces, saliva releases digestive enzymes. When food is swallowed, it enters the esophagus. This long muscular organ carries chewed food from the mouth to the stomach for further digestion. Food is moved along by contractions called peristalsis.
At the bottom of the esophagus, food passes through a muscular valve called the lower esophageal sphincter, or LES, and into the stomach. The digestive juices secreted by the stomach are highly acidic.
When the stomach contracts to move the food into the intestine, the LES closes tightly in order to prevent these acidic juices from moving back into the esophagus where it can cause damage.
A breathing muscle called the diaphragm separates the chest from the abdomen. To reach the stomach, the esophagus passes through the diaphragm at a point called the hiatal ring.
Reasons for Procedure
When the LES does not close properly, acidic stomach contents are allowed to flow backward. This condition is known as gastroesophageal reflux disease, or GERD.
The most common symptom of GERD is heartburn, which is a burning sensation in the mid-chest. Other symptoms may include: sore throat, a feeling of a lump in the throat, regurgitation of food, excessive belching, hoarseness, chronic cough or wheezing, bad breath, shortness of breath after lying flat.
If GERD is not treated, it can lead to a variety of esophageal problems including: ulcers, bleeding, narrowings, or strictures, a kind of cancer called Barrett's esophagus.
A fundoplication is a surgical procedure to treat GERD. In this procedure, a portion of the stomach is wrapped around the LES to tighten it and prevent backflow.
A fundoplication may also be done to fix a hiatal hernia. A hiatal hernia occurs when a portion of the stomach pokes into the chest cavity through the opening in the diaphragm. A hiatal hernia can affect the LES and increase the risk and severity of GERD.
While most cases are due to a weakened LES, GERD may also result from other conditions. If simple measures do not suffice to treat the symptoms, doctors may recommend a number of tests to more precisely determine the cause. These may include: Manometry, which measures the change in pressure in each of the esophageal segments while swallowing pH probe, which descends into the lower part of the esophagus to measure how much acid is present before and after swallowing, upper endoscopy, which uses a lighted tube to directly see and obtain biopsies from the inner lining of the esophagus, stomach, and part of the small intestine.
Surgery should be considered a last resort for the treatment of GERD. Lifestyle changes, sometimes combined with medications, are always tried first. Examples include: losing weight, if necessary, avoiding substances that trigger reflux symptoms, such as caffeine, alcohol, and fatty meals, avoiding snacks at least two hours before going to sleep, propping up the head of the bed to reduce the backward flow of stomach acid into the esophagus.
While some people find that over-the-counter antacids provide temporary relief, many patients with GERD need to take other medications regularly to relieve their symptoms. The two most commonly prescribed medication classes that reduce the production of acid in the stomach are: H2 blockers, such as ranitidine and famotidine and proton pump inhibitors, such as omeprazole. Surgery for GERD is usually only considered if: lifestyle changes and medications do not adequately relieve symptoms; complications develop, such as ulcers, strictures, bleeding, or Barrett's esophagus.
Surgeons are also developing ways to treat GERD using upper endoscopy. For example, surgical instruments can be passed through the endoscope to tighten the LES by delivering a small electrical current, placing stitches, or administering an injection.
In the days leading up to your procedure: Arrange for a ride to and from the hospital. If you regularly take medications, herbs, or dietary supplements, your doctor may ask you to temporarily discontinue them. Do not start taking any new medications, herbs, or dietary supplements without first consulting your doctor. The night before, eat a light meal, and do not eat or drink anything after midnight.
To begin your procedure, an IV line will be inserted into your arm to provide fluids and medication. A catheter may be placed into your bladder to drain urine. You will be given general anesthesia, which will put you to sleep for the entire procedure. Once you are asleep, a breathing tube will be inserted through your mouth and into your windpipe to help you breathe during the operation.
One of two methods may be used for a fundoplication. In the traditional, open procedure, your surgeon will make one larger incision in your abdomen. In the laparoscopic procedure, your surgeon will make multiple small "keyhole" incisions, through which specialized instruments will be passed to perform the surgery.
Your surgeon will begin the open procedure by making an eight-inch incision in the abdomen to expose the stomach and lower esophagus. After separating it from nearby structures, your surgeon will wrap the upper part of the stomach, called the fundus, around the lower esophagus and stitch it into place. This wrap acts as a belt, which tightens and strengthens the LES.
For a laparoscopic procedure, your surgeon will make five incisions, each about one-half-inch long, in the abdomen. Through one incision, your surgeon will insert the laparoscope, which is a long, thin tube equipped with a light and a camera.
The camera sends images to a video screen for the surgeon to view. Gas will be pumped in to inflate the abdomen and make it easier to see. Through the other incisions, your surgeon will use instruments to detach the fundus of the stomach from its surroundings, wrap it around the lower esophagus, and stitch it into place.
If a hiatal hernia is present, it can also be fixed surgically. Your surgeon will pull the herniated part of the stomach back into place in the abdomen and tighten the hiatal ring in the diaphragm to prevent another hernia. This can be done through either an open or laparoscopic procedure. To complete the surgery, the abdominal incisions are closed with stitches or staples.
In some cases, your surgeon may begin the procedure laparoscopically, but then need to switch to an open procedure. Factors that increase this risk include: obesity, bleeding problems, dense scar tissue from a previous surgery.
Risks and Benefits
The risks of a fundoplication include: infection, excessive bleeding, difficult or painful swallowing, requiring a lengthy liquid diet, delayed intestinal functioning or bowel obstruction, recurrent reflux symptoms, need for re-operation to adjust a wrap that is too loose or too tight, or to treat a hernia or ulcer, injury to the esophagus, spleen, or stomach, adverse effects from general anesthesia.
Gas-bloat syndrome is a possible side effect of fundoplication. This occurs when the tighter LES makes it harder for food to pass through. An episode can last for three hours and may include: gas pains, nausea, difficulty belching or vomiting, abdominal distention, and/or increased flatulence.
Eating soft foods and chewing thoroughly can help prevent this syndrome.
The main benefit of fundoplication is the resolution, or significant improvement, of the most common GERD symptoms in 90% to 95% of patients. These symptoms include heartburn, regurgitation, and belching. For people with less common symptoms, such as hoarseness and chronic cough, the surgery is 70% to 80% effective.
A laparoscopic procedure offers some benefits over the open method, although all patients are not necessarily candidates for the laparoscopic approach. These benefits include: less scarring, quicker recovery time, shorter hospital stay, and/or lower risk of infection.
In fundoplication, or any procedure, you and your doctor must carefully weigh the risks and benefits to determine whether it's the most appropriate treatment choice for you.
After the Procedure
When you awake from surgery, you will find a small tube passing through your nose and into your stomach. This tube helps remove fluids and gas from the site of the surgery and is usually removed within two days. You will be encouraged to get out of bed and begin walking the same day of surgery.
You will need to follow a liquid diet for the first few days before gradually progressing to a diet of soft solid foods, which you should expect to continue for up to six weeks. Other dietary measures you will be advised to take during that time include: eating small meals, chewing food well, avoiding chewing gum and carbonated beverages.
The hospital stay after an open fundoplication is 4-7 days, and total recovery takes 4-6 weeks. With a laparoscopic procedure, you may go home in 1-2 days, and total recovery time is 2-3 weeks. Your doctor will prescribe a medication to reduce acid production in your stomach for at least two weeks.
Call your doctor if you experience: difficulty swallowing that persists beyond the first few weeks, nausea or vomiting, redness, swelling, increasing pain, excessive bleeding, or discharge from the incision site, cough, shortness of breath, or chest pain, signs of infection, including fever and chills, and/or pain, burning, urgency, frequency of urination, or persistent bleeding in the urine.
- Digestive system. The Nemours Foundation. Available at: http://kidshealth.org/teen/your_body/body_basics/digestive_system.html. Accessed October 20, 2004.
- Fundoplication. MedicineNet.com. Available at: http://www.medicinenet.com/fundoplication/article.htm. Accessed October 20, 2004.
- GERD - Nissen fundoplication. Columbia University Department of Surgery. Available at: http://www.columbiasurgery.org/divisions/surgical/gerd.html. Accessed October 18, 2004.
- Heartburn. The American Gastroenterological Society website. Available at: http://www.gastro.org/clinicalRes/brochures/heartburn.html. Accessed October 19, 2004.
- Laparoscopic Nissen fundoplication procedure to correct acid reflux (GERD). University of Maryland Medicine. Available at: http://www.umm.edu/surgeryhome/nissen.html. Accessed October 18, 2004
- Laparoscopic Nissen fundoplication. University of Washington Department of Surgery, Center for Videoendoscopic Surgery. Available at: http://depts.washington.edu/cves/lapnis.html. Accessed October 18, 2004.
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