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Determining the success or failure of the Nissen Fundoplication - My Observations

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Posted 3/10/2012 9:42 AM (GMT 0)
I feel I need to write this. The conclusion that I've arrived at, as emphatic as anecdotal evidence can be, is that if you're still getting similar levels of reflux (or even more!) after a few weeks of the wrap then the wrap has not been successful for the purpose of reducing reflux.


The other "healing" people here and surgeons refer to seems to be:

1) Superficial surgical healing - eg incisions
2) Internal inflammation - which causes irritation/sensitivity
3) Resumption of normal motility after the GI smooth muscle took some operative insult
4) Bloating/dumping/dysphagia/spasm/belching etc - probably a function of the above (eg gastroparesis, both temporary and permanent and esophageal spasm).
5) Healing of secondary (extra-esophageal) symptoms, ie symptoms outside the esphagus caused by previous exposure to acid/bile/other enzymes, eg sore throat, respiratory symptoms etc. Healing here would assume a well-functioning wrap.


Other than that, if the basic aim of the operation has failed, ie to lessen the backwash of stomach contents up the esophagus (and beyond), then some of the above healing will not take place and it seems that people are soon aware post-op of whether the reflux has lessened or "gone" (unlikely truly gone) or whether it has not.

There are also anecdotal reports that post-op the wrap is still "misshapen", presumably because of the inflammation, however I have only seen a couple of people who report improving reflux with time (I'm not talking days, but weeks or months). I couldn't find anything in the medical literature on this either.


While it's not a comforting thought, I believe maintaining a degree of realism better equips you to pursue a second operation or other treatment modes if necessary to give you the quality of life you hear about from those who've had a successful wrap.

Of course, this is only my observation of anecdotal evidence (having had the wrap myself, boy did I search), so I'd love to hear others' viewpoints and if they exist I'd be very grateful to read about evidence supporting or contradicting these observations.
Posted 3/10/2012 3:43 PM (GMT 0)
Hi Marcello,

Interesting post.  When you participate with an online forum you're likely to find skewed data, as most who have the surgery never post unless they're someone seeking information to better understand what's going on, or someone who feels that they are not responding properly to their surgery and are looking for answers.

The majority of Nissen patients heal and the go about their business of living a better quality of life until the time that they experience increased symptoms, when they then seek out an online forum such as ours.  Once again adding to the failure perception.

Many past members who had the surgery and found a successful outcome go on their merry way and rarely if ever post here again.

I've written multiple posts and responses that realistically state the likely result of any Nissen.  People with high volume reflux and no LPR symptoms are the most likely to find the surgery a complete success.  People with LPR symptoms are more sensitive to smaller amounts of reflux, and are likely to continue to maintain some of their symptoms, but if their surgery is successful, the symptoms will be greatly reduced.

I've stated often that this surgery can't take reflux to zero.  If that were the case we'd need tube feeding because there would be no way to eat.  Nissen surgeons only attempt to bring reflux back to "normal levels" (a DeMeester score of <14 or so) 

If a surgery has not been successful for the purpose of reducing reflux, the obviously it is a failed surgery.  If that is the case, your surgeon/GI doc need to be visited again and this situation should be discussed. 

The problem with jumping to the failure conclusion is that repeated Nissens become increasingly complex.  Surgeons prefer to give the healing more time before deciding to do a redo.  If you speak to your surgeon, he/she will have a good idea whether or not you might expect some improvement in your results over time and healing.

If you have had the surgery and consider it a complete failure, and have given it the proper amount of healing time to actually determine this,  I would recommend that you do NOT seek help from the same surgeon who performed your incorrect procedure.  Rather, it makes far more sense to research surgeons either within your area or make a trip to a center and seek help from someone else who is more qualified and skilled.  Redos are more complex to begin with, and I can't see a reason why you'd trust the procedure to someone who presumably botched your first one.

Just some thoughts..

Best wishes,

Denise

 

Posted 3/10/2012 9:13 PM (GMT 0)
Marcello

You state that you have had the procedure, what has your recovery been like? I will refrain from any anecdotes about mine as I believe my recovery, although interesting was not at all humorous enough for a short story or accounting.

I will say that this procedure was life altering for me. I had many issues that were resolved because of the procedure. I am not one to dissect the reasons why it worked, I am just thankful it did.

I do hope that your problems were resolved and you are now on the road to recovery.

Reach for the Sunshine.. Rainbows will follow...
Sandi smurf tongue turn smurf tongue turn
Posted 3/11/2012 6:23 PM (GMT 0)
Thank you kyheart, and please don't hesitate to post your anecdotes. My recovery has been good from the 5 points mentioned above (was under the hands of a very experienced surgeon). However, the surgery intention has failed, I've resigned the fact that my wrap seems too loose and I can't perceive any reduction of volume reflux.
Posted 3/11/2012 6:31 PM (GMT 0)

dencha said...

Hi Marcello,
Interesting post. When you participate with an online forum you're likely to find skewed data, as most who have the surgery never post unless they're someone seeking information to better understand what's going on, or someone who feels that they are not responding properly to their surgery and are looking for answers.

The majority of Nissen patients heal and the go about their business of living a better quality of life until the time that they experience increased symptoms, when they then seek out an online forum such as ours. Once again adding to the failure perception.

Many past members who had the surgery and found a successful outcome go on their merry way and rarely if ever post here again.

Hi Denise, true, there's always going to be a selection bias on a forum like this for the very reasons you mention above. How I wish I was in that subgroup!


dencha said...
The problem with jumping to the failure conclusion is that repeated Nissens become increasingly complex. Surgeons prefer to give the healing more time before deciding to do a redo. If you speak to your surgeon, he/she will have a good idea whether or not you might expect some improvement in your results over time and healing.

I'm aware that for other procedures eg cholecystectomies (gallbladder removal), if there is cholecystitis (inflammation of the gallstone), then you either operate within 48-72 hours or else you should leave it for 6-8 weeks as the adhesions (scar tissue) caused by the inflamed gallbladder is chaotic and need time to organise (complication rates for cholecystectomies are highest between the 2 above time periods). I'm presuming a similar timeframe as a minimum for re-operation but I'm not certain and my enquiry has yielded a wide range of answers depending on the surgeon.

My surgeon is very experienced, however he has a difficult case on his hands. I have volume reflux going up to my L&P but I don't have any lasting 'secondary symptoms', just occasionally transient hoarseness, bile taste, chest infection. I think my problem is similar to Bill's on this forum in that I've dysmotility in the esophagus. My main symptom is secondary insomnia and have to adopt a lot of the measures Bill mentions here, which is very debilitating socially.

I am hoping for a 2nd op as soon as the surgeon would do it, if he is.
Posted 3/11/2012 8:32 PM (GMT 0)
Hi Marcello,

I would be very surprised if your surgeon agrees to do the surgery without putting you through the testing again--PH monitor, barium swallow, manometry, endoscopy...He will want to know if your symptom are actually being caused by a failed wrap.

I'm glad that you have a surgeon that you have complete confidence in.  My asthma doc sent me to an excellent Nissen surgeon to determine whether or not my asthma was allergy or reflux related.  After the typical battery of testing he declared my wrap intact and working fine.

I'm sorry you're not finding yourself among the successfully wrapped.  At what stage of healing are you?  Here's hoping that you find some relief soon.

Denise

Posted 3/12/2012 10:10 AM (GMT 0)
Agreed, I'm expecting the full works, at the very minimum a swallow and endoscopy. Will look forward to hear his views. Currently at 4 weeks.

Denise, bearing in mind these diagnostic batteries aren't 100% sensitive in picking up abnormal function (pH test probably closest), did you believe your wrap was fully intact?
Posted 3/12/2012 1:27 PM (GMT 0)
Marcello,

Yes, I believe my wrap is fully intact.  I live in a fairly large city, and the surgeon who did the workup is considered "the guy who does all the Nissens".  I totally believe that his conclusions are correct.

When I had the PH monitor prior to my wrap (I'd had it done 2 times) I suffered greatly during the week prior and testing time due to the effect of not having any PPIs.  My reflux sensations were excruciating.

When I had the PH monitor after my Nissen I was symptom free.

As I have written many times here on the forum, I'm very well aware of the fact that post-Nissen reflux is not eliminated, but rather, reduced.  This can create problems for those of us with atypical symptoms, as it often takes very little reflux to get the symptoms going. 

That said, my lungs have been improved tremendously since my surgery, and I consider it a complete success.  Does this mean I never get reflux?  NO.  I'm certain I get reflux at times, though it is silent and I'm not aware of it.  Could I get some symptoms at times?  Yes that is definitely in the realm of possibilities. 

My asthma doc is well-versed in the effects of reflux on lungs and the fact that an indivdual might not be aware of that reflux.  That is the reason I still take GERD precautions even though I have an intact wrap.  I sleep with the head of my bed elevated, and take a PPI before dinner. 

Prior to my surgery I took 2 doses of 40 mg Protonix as well as 300mg Ranitidine at bedtime, and of course the head of my bed was elevated.  Even with those precautions my lungs were extremely sick and my asthma was uncontrollable even with large (unhealthy) amounts of steroids.

When an individual has a PH monitor post-op there will likely be some reflux reading.  This is why volume refluxers have the best results.  The amount of reflux can be greatly reduced, but not eliminated completely.

If as you say you were a volume refluxer and your DeMeester score was very high, (what was your DeMeester score, if I might ask?) then if you have the testing it should demonstrate a big reduction in your volume if your surgery was successful. 

Best wishes with your quest for information.

Denise

Posted 3/12/2012 6:08 PM (GMT 0)
Thanks for the wishes Denise, interesting to hear about the secondary effects of gerd, glad to hear your wrap was a good one.

I can't remember what exactly I Demeestered but it was above 50. I imagine I'd have a similar score now unfortunately. But hey, here's to a second bite at the cherry :)
Posted 3/15/2012 10:57 AM (GMT 0)
I had a laparoscopic Nissen's 15 years ago. I was aged 22 and healthy and slim (ie ideal candidate for surgery).
Before my op I was on 40mg daily omeprazole and would still need a box of 96 Rennie tablets pretty much every week. Plus all other lifestyle changes.
From the day after surgery, I had no symptoms whatsoever, until the last year or so when I get the occasional bit of reflux.
I had reason to have a CXR this week, and noted that I now have a large hiatus hernia, so my wrap must have come undone at some point... but my symptoms are not really even bad enough to see a doctor at the moment, though I will do, as it's worth having a scope I think.
One of my colleagues at work has also had one, with perfect outcome too, so please be assured that this procedure can work, and does work. But it's like anything, it may not last forever.... that wouldn't stop you buying a car or a computer...
So I'm not bitter that my Nissen's appears to have 'failed'. It was a resounding success for many years, and if my symptoms recur as they did as a student, I will not hesitate to get it redone.
Posted 3/15/2012 1:42 PM (GMT 0)
Interesting post ohahjames.

You also add more weight to my suspicion, which unfortunately not many (including myself) seemed to be much aware of, ie that, generally speaking, you notice the reduced reflux almost instantly after the surgery and not later on as some surgeons seem to be suggesting to their patients.

Your post is also exactly why I'm not going to hesitate to try to get it redone too, and why everyone should be forthright and proactive about reporting refractory reflux post-op, instead of settling for less than your potential quality of life by yielding to and normalising your suffering.
Posted 3/15/2012 10:28 PM (GMT 0)
Hey guys,

I just saw my surgeon today. I told him my symptoms of my burning throat, mouth, and lips, and he said it's not reflux. It maybe an allergy issue he says. He says to come back in a month but if I really get back to call him early an we can schedule something.

I saw a dermatologist the other day and his had suspicion of autoimmune disorder which I had blood test recently done for. He also doesn't think it is reflux.

I got the nissen to stop this and it did improve my stomach pains oddly this is the symptom I thought would not improve.

Well, I'll keep you updatetd...
Posted 3/16/2012 10:22 AM (GMT 0)
Hi Max, yes your symptoms (eg repeated 'burning' of your mouth and lips) didn't really sound like ongoing classic reflux. I wouldn't completely discount your Nissens until they're sure, because maybe your symptoms were precipitated by it. Glad your seeing a dermatologist, hopefully you get relief
Posted 12/29/2014 5:06 AM (GMT 0)
Marcello, I read your posts with great interest.

I had a NF a few weeks ago and upon waking had the same raging reflux I had pre op and continue to have it to this day.

I consider myself one of the unfortunate 20% for whom the FN was ineffective.

I would very much like to know what transpired for you since your last post...

Hoping very much you're still an active participant.

Thank you,
Roxanne
Posted 12/30/2014 11:58 PM (GMT 0)
Here is a really interesting study on the subject:

http://www.surgery.usc.edu/foregut/demeesterpub/316.pdf

If you don't include the importance of having a great surgeon, there are basically three factors that are important for the outcome of the surgery. 1. The most important one is to have an abnormal 24-hour ph monitoring result. 2. That you suffer from a typical symptome (like hearthburn). 3. That your symptoms improve when using PPIs.

With these factors present, there is a very great chance the surgery will be a sucess for you.
Posted 12/31/2014 11:32 AM (GMT 0)
I am the "loud-mouth" of the group and am always posting my positive results. Mine was 100% successful so far. I have had zero reflux since the day of the operation 1 year and 9 months ago.

I silently suffered with reflux for 40 + years because when I was originally diagnosed with a hiatal hernia, the operation was horrendous. Its a wonder that I didn't get Barrett's or cancer.

My Hiatal hernia allowed a large portion of my upper stomach to migrate into my chest cavity. During the barium swallow test, when the radiologist put me in the horizontal position he could watch the barium flowing back into my esophagus on the fluroscope every time I swallowed.

I could also feel the contents of my stomach being forced upward into the esophagus every time I flexed my abdominal muscles. During the operation my Surgeon put three stitches in the hiatus to close up the excess gap and did a 360 floppy with a bougie inserted to ensure it wasn't too tight.

My Surgery was done in a military hospital and my surgeon was a general surgeon. I had no choice, but it was a teaching hospital and he was he teacher. I don't know if he did the physical part of the surgery or if it was one of his assistants. I only know that for me the results were perfect (so far).
Posted 12/31/2014 6:26 PM (GMT 0)
I had Nissan Fundoplication surgery on 12/3/2013. I had slight pain and was doing fairly well. On 12/24 I began to feel very weak and by Christmas morning had a horrible pain in my back and side. I called my surgeon and was sent to the hospital for a CT scan. My surgeon discovered that I had a blood clot in my spleen. I was sent directly to the hospital and admitted. I spent 6 days in the hospital while they tried to get my blood thinned to a safe level. I saw a hemotologist who ran every blood test avaliable to include genetic testing. All of my blood tests came back fine. Both doctor's were unable to determine what caused the blood clot. I took warfare for 6 months and still give blood periodically. It has taken me a full year to recover and am doing well.I thought I would share my experience as my surgeon could not find any reports of anyone who has had this surgery developing a blood clot in the spleen.
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