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Fundoplication

 

Introduction

Gastro-Oesophageal Reflux Disease (GORD) is a common condition where the acid fluid of the stomach intermittently “refluxes” up in to the oesophagus through the Lower-Oesophageal Sphincter (LOS) (See the diagrams). This causes heartburn, reflux, altered taste, sense of fluid in the mouth when bending over or sleeping, coughing especially at night, and can be severe and debilitating. Hiatus hernias are distortions of the stomach at the diaphragm and are associated with GORD. Most people with GORD achieve good symptom control by taking acid relieving medication. Sometimes the medication fails to do this properly, the patient does not like taking medication or frequently forgets and has only poor symptom control, or the fluid enters the mouth and so the medication only solves part of the problem. In all these situations anti-reflux surgery can be considered.

Fundoplication (“fundus” is the upper stomach, “plication” means to rearrange, so “rearranging the upper stomach around the LOS”) is commonly done laparoscopically and is a common choice for people unsatisfied with the results of medication who are fit for surgery.

This type of surgery has been available for many years and has been refined over that time and is now very effective. Over 98% of people who have this surgery achieve highly satisfactory symptom control. There are a number of different operations available.

The oldest and most proven of these is the Nissen Fundoplication, which is done laparoscopically in most cases. It is named after it’s designer (Nissen) and involves complete, 360 degree wrap around the lower oesophagus-stomach junction.

Laparoscopic Fundoplication - normal anatomy

The stomach should be completely below the diaphragm. It has a valve at its upper end called the lower oesophageal sphincter and a flap valve effect created by its shape. These features prevent the acid in the stomach entering the oesophagus, which is what causes the symptoms of GORD.

 

The best operation

Nissen Fundoplication is the Gold Standard operation, meaning it is the best, it sets the standard and all operations are compared to it. The Nissen Fundoplication has remained the Gold Standard for decades and is the operation of choice. However, there are situations where other operations may be preferred. The decision regarding the most appropriate operation for you is made with your surgeon prior to surgery. This operation improves the ability of the oesphagus to keep acid down in the stomach and stops the symptoms of GORD in 98% of operations.

Preoperative evaluation may include tests such as gastroscopy, barium swallow, pH and manometry testing. The surgery is less effective in some circumstances such as obesity, certain medical conditions and when there is abnormal oesophageal function. Barrett’s Oesophagus is a condition where there is an increased risk of developing oesophageal cancer. This risk is mitigated somewhat by this surgery.

Incisions - Fundoplication

 

How is it done?

Five small (5 to 15mm) incisions are made in the wall of the abdomen and instruments introduced through them. The inside of the abdomen can then be visualised and the upper stomach separated from the surrounding structures. If a hiatus hernia is present, then this is repaired by repositioning the stomach below the diaphragm and narrowing the gap in the diaphragm by either suturing it or using mesh.

For a Nissen Fundoplication the stomach is wrapped 360° around the LOS and sutured in place. Larger hernias may require additional measures. Sometimes a modified operation is required where only 180° or 270° of the LOS is wrapped by the fundus.

Laparoscopic Fundoplication - Hiatus Hernia

With a Hiatus hernia the stomach has protruded through an enlarged gap in the diaphragm and this effectively weakens the barrier between stomach and oesophagus and acid freely swishes up in to the oesophagus. When the volume of fluid is large this creates “volume reflux”, which is not responsive to medication.

 

Then what happens?

Over 98% of people have no reflux symptoms the moment they wake up from their surgery, never needing to take medication for this problem again. Some people experience difficulties with swallowing, belching and flatulence after the surgery but this settles down after a few months usually. Patients need to have a softened diet for 2 to 3 weeks post surgery to enable the sutures to heal.

 

Operative Risks

For any operation there are risks, and in particular there is a risk of infection, bleeding and injury. The overall risk of major complications is 2%. The specific risks in laparoscopic fundoplication are bleeding (1 in 200), and injury to a nearby organ or structure (1 in 200). Surgery is required generally to repair these, and sometimes extensive surgery. The risks of the surgery are greater if there is scar tissue from previous surgery, in revision surgery and for complex hiatus hernias. Revision surgery is required in 2 to 5% of cases The most common outcome is no complications or a minor problem that will pass such as wound infection (5%). Conversion to open surgery is required in around 1%.

Mr Draper has performed well over 100 Laparoscopic Fundoplications, on top of around 1000 laparoscopic stomach operations and the current complication rate is less than 0.5% and in 3% revision surgery has been required.

All figures are approximate.

 

Post Operative Recovery

Most people are ready to go home 1 or 2 days post surgery and need 2 weeks convalescence before returning to work. Postoperative problems such as pain, shoulder tip pain and nausea are usually easily managed. The dietary changes required postoperatively for 2 to 3 weeks will be clearly explained to you by the dietitian, whom you will meet preoperatively.

 

More Information

This brief information sheet is best considered a reference to be used in conjunction with discussions with your surgeon. For further information discuss your operation in detail with your surgeon, visit our website geoffreydraper.com.au or read other information sheets such as our Patient Advice Sheet.

 

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