Why Does Fundoplication Go Wrong for so Many!

Hi Barry,

The truth is, it doesn't go wrong for many people, but you're one of the unlucky ones.  The vast majority of people who've been "wrapped" never post a single word online.  It is those with problems who seek out information and support on the internet.

I've come to believe that most of the scary posts you and I read before our surgeries were from people like those we read about here--post-op patients who are in the midst of recovery and are have been misled by their surgeons that they'll be eating normally, running, playing golf, and back to normal in a couple weeks or so.  They are afraid that the symptoms they're having in their recoveries are going to be with them forever. The vast majority of the old scary posts that you find all over the internet are old because problems resolved over time.

That said, there are certainly those like yourself, who do not respond well to the surgery.  Why?  There are a number of reasons I've gathered from my discussions with surgeons and research here.

Surgical incompetence is one.  This includes surgeons who do not do proper testing to make sure their prospective patient is indeed one who will be helped, not harmed, by a Nissen surgery.  It also includes surgeons who don't have the prerequisite skills or experience to create a functioning wrap (and create one that is too tight, not positioned properly, the wrong kind (full wrap on someone with motility problems, etc.).

I remember discussing with my surgeon the fact that it is critical to find an experienced and skilled NISSEN surgeon.  He pointed out that it is equally important to make sure (through testing) that the patient is the right one for surgery.  If an individual is not right for surgery (ex: symptoms not caused by GERD, motility issues, stomach emptying issues, etc.) then it is important that the surgeon know that, and not go forward with the procedure.

Sometimes people overdo it during the recovery stage--lifting heavy objects, etc. and tear the repair before it has become fully scarred over and strong.  Stomach viruses or food poisoning can cause retching/vomiting which can tear out a healing wrap. This is why we advocate that people always carry anti-nausea drugs with them.

And then there are the tiny cohort of outliers...that have done everything right, and still something has gone awry.  Perhaps an underlying issue was missed by the testing. 

Indeed, for you, Barry, the Nissen was a mistake.  You are, unfortunately for you, but fortunately for most, in the tiny minority of Nissen patients who have been made worse by the procedure.  The vast majority are helped greatly. 

I'm one of those.  I had uncontrollable asthma that was being made that way by reflux.  It wasn't even a lot of reflux.  I knew that the odds of the surgery helping me was 75-80% (because my symptoms were atypical) and I went forward hoping that I'd be in that cohort.  Thankfully, I was.  My PCP was encouraging me to have the surgery for years, but I dragged my feet, simply because of the scary online posts you're referring to.  I ended up with permanent skin damage from the high doses of steroids I had to take to keep me breathing prior to surgery.  I just wish I'd had the courage to have the surgery much sooner. 

Those scary online posts are definitely off-putting.  Keep in mind that people posting online are only a tiny minority of all patients who've had the procedure done.  I'm an outlier in that I've had a great result from my surgery and yet I stick around the forum (as do Bill and Joy) trying to help others who are struggling through their recoveries. 

I am a teacher, and I guess the opportunity to teach and support was calling me to continue sharing and helping others here.  There aren't many who take the time to do that.  Only Kitt, Bill, and Joy remain from the time I came to the forum seeking out support during my recovery.  Most get support and information here at the forum, and when they have recovered, go on about their lives and forget all about us!  There are a few who stop back once in a while to share their good experiences, but most forget all about Healing Well.

So I guess the answer to your question is that for many, the Nissen is absolutely the RIGHT way to go.  The reason you see more bad than good is that you're getting a skewed view of things because of the reasons I've already discussed in this post. 

I'm sorry that you haven't found answers to your problems and that you're having such a hard time.  I do, however, disagree with your premise that the Nissen is a problem for most.  In fact, the Nissen is the SOLUTION for most.  I just wish it had worked out for you, my friend.  It's hard to see you suffering through all this.

Very best wishes,

Denise

 

Hi,thanks for the replies.I guess im just unlucky then.When I asked my Gp why he didn't recommend surgery he said simply that it doesn't work and that it causes more problems,people always end up back on ppis aswell. Now its " I told you so"when I go to see him. Im not giving up yet theres got to be something or someone out there that can fix this. Barry

Hi Barry,

As I said before, there are outliers who have problems after surgery.  I don't know why your PCP was so negative on the surgery.  I wonder if he was suspicious that your problems weren't primarily caused by reflux.  In contrast, my PCP was instrumental in getting me into surgery.  He and my asthma docs were confident that my problems would be helped by the surgery.  I was actually one of the people getting in the way of going forward with the surgery.  Like you and everyone else who searches online, there were many negative things out there, and I was fearful. 

My GI doc was less sure that the surgery would help, as my issues were not high volume/episode reflux, which is the "sure thing" fix for the Nissen.  Atypical symptoms are the trickier.  Still, my PCP was so frustrated with my GI doc, who wouldn't refer me to a surgeon, that he did it himself.  I didn't use the surgeon he sent me to (who did more testing and said I'd be a good candidate--I'm sure largely on his respect for my PCP's opinion), but rather, took the testing and my PCP's obvious frustration, back to my GI doc for consideration.  At this point my GI doc did another PH monitor, which was higher, although only a hair above "normal". 

When I saw him for the follow-up he said that I could continue with medication (and horrible, unhealthy lungs, as the medication hadn't been helping) or he would refer me to a surgeon (and I wouldn't have to go immediately).  As you can see, he was the one who didn't think the surgery would help my lungs.

I went to the surgeon as soon as I could get an appointment, and three weeks later I had the surgery.  My lungs were in "life threatening" condition, and I had no other options.  I didn't know if the surgery would help me, but I knew I had to try it.  I figured it would rule out GERD if it didn't work.  Then it would be back to the drawing board.

I still take a PPI an hour before dinner on the recommendation of my asthma doc and PCP (in contrast to my 40mg before breakfast, 40mg before dinner, and 300mg Ranitidine before bed, high doses of steroids, nebulizer treatments, and lungs that were still filled with mucous).  Since reflux is still possible after the surgery (if the wrap was tight enough to stop all reflux, you wouldn't be able to eat) I am taking it proactively, just in case.  I also continue to sleep with the head of my bed elevated for the same reason.

Does this mean my surgery isn't successful?  Absolutely not.   My reflux episodes are miniscule and extremely seldom compared to prior to surgery.  I wouldn't do any of these things if my lungs were not asthmatic and highly reactive.  I now have healthy lungs that are back to normal conditions.  I do have pollen allergies and still have asthma, but they are under control.

Perhaps your PCP had referred patients to a surgeon who didn't have good outcomes, and had gotten a lot of patients back with problems.  Perhaps he/she didn't think your problems would be resolved by surgery.  I don't know the details enough to understand what happened in your case.

DOGBONES, the surgery is not a "cure" in that it doesn't put you back to the condition you were in prior to GERD issues.  It doesn't make your LES young and functioning.  It is, however a cure for the problems of many GERD sufferers.  In my case, it was a cure for the reflux-induced lung disease from which I was suffering. 

 For people who have painful and frequent reflux, it is a cure for the majority of their suffering.  Might someone need a PPI after surgery?  Yes.  But studies show that the amount of PPI is much reduced, and people are still very happy with the outcomes even with that necessity.  The vast majority of people get relief from symptoms to an extent that allows them to sleep again, and achieve a much better quality of life.

I don't recommend having the surgery simply because you don't want to take PPIs again.  I don't think it's enough of a reason, and there are no guarantees that you'll never need them.  If PPIs aren't effective, and your GERD is out of control, that's a different story.  In that case, the surgery is worth a try. This surgery has been done for nearly 60 years, though the laproscopic version has only been done nearly 20 years.  It has helped countless people.

It shouldn't be taken lightly, and someone who is contemplating going the surgery route should understand that it is a great option, though not a perfect one.  There are few perfect options in life.  I'm glad I took the chance and found relief and good health again. It's an individual choice that should be taken with care.  If you're the right person for the surgery, have chosen a surgeon carefully, and are ready for a challenging recovery (although not so challenging as I'd expected...see my recovery journal: https://www.healingwell.com/community/default.aspx?f=45&m=2183443) then go for it.  I did, and I'm living a much healthier and happier life as a result.

Barry, I hope you find an answer to your suffering.  Bill is probably a good one to talk to, as his first Nissen was done wrong, and although all tests showed it intact, when his new surgeon went in to see explore what was going on, he discovered it had been done improperly.

I wish you all the best!!!

Good luck,

Denise

Barry, I am one of those people that had the surgery two years ago.  I can now tell you that I am happy I did it.  It took a long time with the healing process.  I just had a barium swallow done and my surgeon said that everything is great.  I must say though, it took me this long for the quirks to subside. 

I no longer exercise the way I used to especially with weights.  I do mostly running and a little weight training.  I don't want to take the chance of wrecking the wrap.

I am sorry to read about your issues.   Denise is right, most people that have healed have and will move on from Healing Well.  I still read everyday but I certainly don't post anything.  

Take care

Bibi

Had NF 16 months ago. Still have reflux and LPR but not as bad as before the surgery. The issue since the surgery is that I can no longer take PPIs due to severe stomach pain they cause. I took PPIs before the surgery without any problems. I had a root canal recently and I could not continue taking pain medication due to stomach pain once the medication wore off.
I now also have IBS which I believe is a side effect of the surgery. (This is much worse than dumping syndrome.)
My GI doc doesn't have much advice for me at this point; I believe that this condition will be lifelong.
Would I have the surgery if I would have know of the problems. NO.
I would have taken PPIs and continue on my GERD diet.

Hi all,
I am 22days post op my full wrap Nissen and couldn't be happier. No drugs, no PPIs and I'm eating slowly, almost anything I desire. I saw my surgeon today and he advised me to not lift anything heavy enough to cause increased abdominal pressure from now on...and that includes heavy lifting, or wretching with flu or food poisoning, so he provided me prescriptions of zofran and compazine.
I have absolutely no regrets at having had this surgery; I would advise anyone who is suffering as I did to speak with a GI doc and get a Nissen specialist, as I did. I was diagnosed with Barret's esophagus after suffering for over 10 years with indigestion through out the day and severe reflux at night, or if I bent over . For me, this is better than having the question of whether or not the Barret's would turn into cancer hanging over my head .
Barry, I am sorry that things haven't worked out for you. I got quite a bit of info from this forum before my surgery and asked for things I read here of my doctor before hand. I would not have undergone this surgery if I had gotten a bad feeling from all the people writing on this blog. I , like Denise, think you have to scan through some of the posts as some people may have undergone the surgery when in fact they were not screened properly before hand.
Best of luck to you, Linda

www.bmj.com/content/337/bmj.a2664.long

Hi everyone

This article appeared in the BMJ recently. It's a five year look back study following about 800 people with GORD/GERD. At five years they observed that people who had LN had better relief than those having medical management (medication). This is the "principal findings": -

"After five years, a policy of laparoscopic fundoplication among
patients for whom reasonable control of GORD symptoms
required long term medication and for whom both surgery and
medical management were suitable continued to provide better
relief of GORD symptoms with associated improved health
related quality of life. Despite some narrowing over time, the
difference in the primary outcome measure remained highly
significant at five years. There was reassuringly little evidence
of new chronic symptoms caused by surgery. Reoperations and
complications of surgery occurred early after surgery and were
uncommon."

Most studies show a high level of satisfaction with the surgery. They have also found a lot of people still take PPIs after surgery, but they haven't been able to prove any particular reason for this - one study cited problems with acid rebound as a reason, whilst also noting patients with depression also report more symptoms after surgery.

We hear quite a few people on the forum having problems after surgery, but it often seems the case that when tested they don't have reflux. I think as Denise and others have said, those that are completely trouble free are out there having fun and not spending much time on the forum!!

I wonder Baza, whether you've seen the research on Symprove? It's a liquid probiotic that has had a proper medical study gut.bmj.com/content/61/Suppl_2/A104.1.abstract and seems to have good feedback on Amazon etc in relation to its benefits for IBS. Maybe worth looking into?

MMM

Barry,

Did your PCP recommend the surgeon?  Is it possible that the surgeon you had didn't have a great track record, and your PCP was gun shy because of it? If a PCP sees lots of patients from a surgeon who doesn't do the Nissen procedure correctly, it's no wonder that he/she would have a skewed view against it.

As I said, my GI doc was concerned that my low DeMeester score was an indication that the surgery wouldn't work.  I do know that there is always a concern that a patient's symptoms aren't truly GERD related (in my case asthma, which had more than one cause...pollen and reflux).  In those cases, there is the possibility and sometime probability that the surgery will not alleviate the symptoms.  Thankfully, my PCP persevered and kept pushing both (scared) me, and my GI doc.

I hope you can find someone who will help you with your problem.  I hate the fact that you're still suffering.  I'm sure it's very frustrating.

Good luck!

Denise

Sorry it's Roger that mentioned IBS!

MMM