The goal of any elective surgical procedure is to find relief from the issues that necessitated the surgery. In the case of GERD, typically surgical procedures are performed after all other means to reduce the symptoms of acid reflux have failed. Unfortunately, in some cases, relief is not always lasting. This RefluxMD member elected to have a surgery five years ago, but now experiencing Nissen fundoplication complications.
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I had a full Nissen wrap 5 years ago and since then I have been taking omeprazole. Until 6 months ago I’ve been basically symptom free. Recently, I have had very bad chest pains and frequent belching with some reflux. I went to the cardio doctor and my EKG was normal and I’m scheduled for a stress test to rule out heart problems. Is it possible for the wrap to come loose and cause symptoms again? I had an upper GI and was told that I have a hiatal hernia, but nothing was ever done with it. What can be done to fix the symptoms of the hiatal hernia if I already had a Nissen fundoplication?
Thank you for your questions and I am sorry for the reoccurrence of your symptoms. I would like to highlight for others your pending stress test. It is absolutely imperative that any potential heart issues be evaluated and ruled out before proceeding to GERD evaluation and treatment. Typically, a Nissen fundoplication procedure will resolve any hiatal hernia issue. To get more clarification on this, I sent your question to Colleen Gaughan MD, a GERD expert serving the Philadelphia area. Dr. Gaughan performs many types of antireflux surgeries, including Nissens and the new LINX procedure. Here is her response:
Unfortunately, the most common reason for a Nissen fundoplication to fail is a recurrent, or new, hiatal hernia. The most common solution is to treat the GERD again, either with medical therapy or with re-operative surgery. Of course, re-operative surgery is more complicated and should only be performed by experienced practitioners. I would recommend a repeat evaluation with pH testing and esophageal manometry to better define the cause of your symptoms, then a treatment plan could be made for your recurrent symptoms and possibly recurrent reflux disease.
We know that if you previously had a hiatal hernia, it was repaired with the last procedure. However, the original hiatal hernia may have recurred. The other possible explanation is that you may have developed a new hiatal hernia. In either case, you are now experiencing a new set of painful symptoms.
What is a Nissen fundoplication antireflux procedure?
This is the most common, and oldest antireflux procedure performed today. This procedure is designed to reinforce the lower esophageal sphincter (LES), which has failed to close properly. To accomplish this, a portion of the stomach is wrapped around the area containing the LES. Once the wrap is complete, it is sutured along with the esophageal hiatus, the opening in the diaphragm where the esophagus passes, to prevent hiatal hernias. The following image illustrates a completed Nissen fundoplication with the wrap highlighted:
Source: Dana Hamers via Wikipedia
How effective are Nissen fundoplication procedures?
In a research article by Renee Minjarez MD and Blair Jobe MD titled Surgical therapy for reflux disease, the authors state that laparoscopic Nissen fundoplications, when performed by experienced surgeons, had a 90% satisfaction rate over the first five years, and an 88% satisfaction rate over ten years. I want to emphasize that those results are for surgeries performed by GERD experts and anyone considering antireflux surgery should seek out one of these top specialists.
Doctors Minjarez and Jobe also noted that a redo antireflux procedure is necessary in some cases. “Of patients undergoing laparoscopic antireflux surgery (LARS) 2% to 6% eventually require reoperation. Reported mechanical causes of failure vary significantly among studies, but transthoracic herniation occurs in 10% to 60% of failures and “slipped” fundoplications are responsible in approximately 15% to 30% of patients. Tight fundoplication, missed motility disorders, and paraesophageal hernias are other modes of LARS failure.”
Recommendations concerning redo surgeries
The good news is that if your previous Nissen wrap has slipped, or if you have developed a new hiatal hernia, these too can be repaired and you have a very high probability of returning to a symptom-free life again. Here are some suggestions for your consideration:
Have a complete evaluation
We agree with Dr. Gaughan, 24-hour pH testing and esophageal manometry should be performed to validate your condition, determine all your options, and develop a treatment plan.
Find an experienced redo surgeon
An expert is essential for an initial Nissen, but it is even more critical with a redo. According to Doctors Minjarez and Jobe: “Redo surgery can be technically challenging in even the most experienced hands. To provide a durable repair, the cause of the failure must be unequivocally identified so as to avoid a subsequent failure; this mandates that the entire fundoplication be dismantled prior to reconstruction.” If you proceed with a redo, be certain to find a GERD expert that specializes in this type of surgery.
I hope this helps
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