Nissen after TIF

In TIF's literature online, it is claimed that one can still get Nissen done after an (unsuccessful) TIF. However, I am wondering that ... if for TIF they have to pull down the stomach tissue around LES, then would they still have enough on the fundus end to do the Nissen wrap?

I do see some mention of having to do Nissens after TIF in the clinical studies - but I wonder if Nissen's odds of being successful are still the same when doing them on top of the TIFs.

Post Edited (PPI-LESS) : 12/29/2011 5:59:24 AM (GMT-7)

PPI-LESS-

They get the fundus for the wrap by freeing it from the spleen. So I think it is very possible to have a good nissen after the TIF. My first nissen was done wrong and the surgeon didn't release enough from the spleen to make a tension free wrap. This was corrected during my first redo.

Take care,
Bill

I just returned from a second surgeon at major University and he's not for or against at this point. Thinks there may be a good place for it as a "Silver" standard some day. I would be more inclined to try it if it was covered by my insurance - which it is not, so if I am going to do surgery, I want to make sure it is covered as much as possible.

I had my first visit yesterday with a new GI at the Mayo Clinic in Jacksonville.  500-mile round trip!  Had all my charts with me, plus my prepared notes and history.  I've never had a doctor spend an hour and fiteen minutes with me, ask lots of questions, take notes, etc.!  In spite of all my evidence, he, however, remains very skeptical about my symptoms, and wants to proceed slowly.  (I'm finding that GIs HATE LPR symptoms!!  Nearly impossible to diagnose correctly, or treat.)  On one hand, I appreciate his caution, but on the other, I'm very frustrated that I'm still not making any progress in getting this resolved, or moving in one direction or another.  I want to get this over with!  He wants me to get a barium swallow and impedence test, and return with those to consult with the GI surgeon. He did concede to me, that those reflux patients who exhibit "atypical" symptoms are at a much lower resolution rate following surgery than those with typical symptoms.  I knew this, but it's sobering to hear from him.  On almost a lark, he wrote me a prescript ion for nortryptilene -- a tricyclic.  It's normally an anti-depressant at higher dosages, but they've found that at low dosages, it can serve as a "de-sensitizer" of the esophagus for those patients who are predisposed to being abnormally sensitive to the irritation of reflux.  (In his opinion, nortriptylene is superior to amitriptyline.)   He suggested that since my reflux is now in the "normal" range (per my latest Bravo study), that perhaps this might help...but at least "worth a shot" since I'm pretty much out of options.  Now *I'm* the one who's skeptical, but I'll experiment with this and see if I notice any difference. He asked what persuaded me to go with the TIF instead of the Nissen, and I explained my reasons.  Mostly that the TIF was less-invasive, offered good hope, and wasn't as radical as the Nissen, as well as the possible complications that can arise from the Nissen...and basically having my guts rearranged!  My reasons resonated with him, and he's glad that I'm well-informed and resistant to the idea of major surgery...and not impulsive. I'm at the Mayo Clinic because both my local GI and the TIF surgeon have sent me there, and both of them told me that the Nissen is my only option at this point.  Not a good prognosis, but I'm trying to move forward one step at a time...albeit S  -  L  -  O  -  W  -  L  -  Y!!!!!  If someone put the surgical order in front of me right now, I couldn't sign on the dotted line for a Nissen.  I'm trying to prepare myself for that, and perhaps if I'm faced with an ultimatum, maybe the choice will be more straightforward. I asked him if there are any special considerations or limitations about doing a Nissen on top of a TIF.  He said he's not a surgeon, and will defer that opinion to the Mayo surgeon when I consult with him after the new tests. I really appreciate the fact that this resource, the HealingWell GERD forum, is here, and offers the community support it does.  It helps me to read through posts, respond here and there, and in general think my way through this mess! PPI-LESS...I know EXACTLY where you're at.  My quality of life these past three years has been in the toilet.  Yes, we can still "function" day in and day out, but the misery and limitations makes life a chore, and, for the most part, joyless... -Bruce

Hey PPI-Less,

That's pretty much where I am, too. I need further testing (pH monitoring, namely) but the heartburn/regurgitation/discomfort is becoming pretty unbearable and I can't see any other way of dealing with it. I mean, if the whole problem is that the acid won't stay put, I can't see how the Nissen WOULDN'T help us (except in cases like Denise has said, if someone is super sensitive to the reflux).

Best of luck to you! Please keep us updated on your progress. Have you seen a surgeon yet? Has a doc (GP or GI) recommended the Nissen to you?

Ashley

Thanks Ashley,

I got pH/Impedance test done recently and it does indicate reflux (I still need to get the final test result report with the demeester scores etc. from the GI).

The last I spoke with my GI - he gave me two options (given - that I can not take the meds):
- Surgery (however Nissen only - he does not want me to do TIF)
- Wait and see how / if the symptoms evolve in another 6 months to a year.

I don't think I can last out 6-12 months - given my quality of life.

I see my GI again in the next 10 days or so and then will make an appointment with one of the 2 surgeons he recommends. Meanwhile, I am also seeing 2 other surgeons who do TIFs (one on the 17th and another one on the 25th).

I will report on how it goes with these appointments .. but I am hoping I can take a decision in the next 6-8 weeks.

Best of luck to you too!

Bruce
Please let me know how you make out. I had tif done 10/31/11 and now out of the blue i have pressure in throat and its sore.Going to ent and having endo done friday. i think the worst part of the tif is that dont tell you it can make it worse. i had it done thinking it either worked or it didnt. Now I think I might have to have nissen done. This sucks . If I knew then that it could have been worse I would have waited a little longer. Again keep in touch and good luck. I think Im going down the same path as you
Steve

Hi Steve --

I'm really struggling with continuing the motivation to forge ahead with this...don't know what I'm going to do, especially with such an apparently low success rate for "respiratory reflux". Best wishes with your test on Friday.

I also should add that the nortriptylene therapy was a failure, too. I made it two days on the extremely low dose pills, but had to stop because of dizziness and impairment.

-Bruce

Hi Bill --

I guess I didn't clarify in this thread. It's not simply respiratory reflux and the Nissen, it's those patients with respiratory reflux, plus either are intolerant of, or don't respond well, to PPIs. The reasoning is this: it's simply impossible to achieve 0% reflux with surgery or meds. Those patients who respond well to PPIs have demonstrated enough resilience to the remaining reflux to no longer be symptomatic. When those patients have surgery, they achieve approximately the same, or a little better results in terms of reflux suppression...hence, successful procedure.

A small minority of patients are more sensitive to small amounts of reflux. For those patients who don't achieve good results with PPIs, they aren't going to see much better suppression with surgery. This is where I'm at, unfortunately. As a result of my TIF procedure, I'm already pretty close to what can be achieved with a Nissen, but the doctors want confirmation of my current reflux status, as well as an indication of how high it's traveling, so I have to schedule an impedence test. Then they can advise me, yay or nay, about what continued surgical intervention might/might not offer.

-Bruce

Well...this is where I'm getting into the unknown. I did have success with the H2 blockers early on, but I don't believe my reflux was at the stage of severity it is now. It is true that Nexium helps my symptoms, so, in that respect it seems to indicate that surgery should work. But when the GI and the surgeon looked at my Bravo results, they both shook their heads and said that I have really, really low reflux now, and that a Nissen shouldn't improve upon that much.

Now, I did point out the fact that I still had ~30 or so episodes during the 48 hours. Even though they might be of short duration, the surgeon still agreed that that number could produce the symptoms I have. However, he also said it's entirely true that I could have great results from the Nissen, that would disappear in 4-5 months, and then I'd be left with nothing to show for it, plus all the additional caveats from the wrap itself.

The kicker in all this is the botched Bravo I had last time. I can't remember if I mentioned this previously. The nursing staff gave me a Reglan tablet ahead of time as a matter of protocol for EGDs, to prevent nausea. They didn't realize the side-effect of tightening the LES, and this corrupted at least the first 24 hours of the study. This is one of the reasons the Mayo doctors want an impedence test. It's entirely possible that my reflux is worse than the Bravo indicated, and, that the Nissen could offer an improvement.

I really, really hate all this! All the time, and money, and brainpower I'm devoting to this, that could go in more productive directions...

-Bruce

After thinking about this some more last night, I think I know why the doctors include the patients who are intolerant of PPIs in their prognosis. Those patients who have a high sensitivity to reflux sometimes find it still necessary to continue PPIs after surgery to try to get closer to that magic "0%" number. The respiratory reflux patients, of course, wouldn't be able to take the PPIs because of the side-effects, hence, the surgery fails to resolve symptoms in this subcategory.

Maybe?

-Bruce

To answer question about the tif surgery what im saying is before the surgery i didnt have trouble with my throat. I feel that the surgery made me worse because in the past I could go a week without any meds but all of a sudden 9 weeks later im hurting in the throat. I have to say im scared to death that i made the wrong decision and should have waited to do something else. Ive posted asking if anyone has had a nissen after tif and it looks like bruce might be going down that road.I saw ent today and as i thought acid on vocal cords is why i feel a lump. I really wonder if a nissen would be the answer because now im worried the surgeon messed up the les muscle and there is no return. God i wish i could find an answer as bruce has stated its a lot of time and brainpower it's crap you put trust in doctors and it seems that if it doesn't work oh well move on to someone else. Need to vent.

Is the impedance test to measure the refluxes in esophagus and larynx?