Does vomiting undo a nissen fundoplication?

Jamosca,

My only issue causing GERD was a weak Lower Esophageal Sphincter. I had the luxury of being able to select the Classic Nissen Fundo with the longer wrap length, as my "first choice" for a mechanical "cure."

Others who have additional issues causing stomach problems are not necessarily good candidates for any type of Nissen Fundoplication procedure. And, sometimes, GERD is mis-diagnosed by surgeons as the underlying problem when it is not.

Life is full of "trade-offs" and occasionally the durability issue has to take second place in importance - subordinate to a mechanical solution that will function correctly in those cases where a week LES muscle is not the only problem.

There are of course, different degrees of the fundoplication wrap available for differing patient conditions. When conditions permit, the Gold Standard in the treatment of GERD is the Laparoscopic Nissen Fundoplication (LNF) - which is in every case a full 360 degree wrap.

Certainly, I am not qualified to tell you whether you are a candidate for the Classic Nissen procedure. A good and highly experienced surgeon should be able to help you with that determination.

The Holy Grail in patient comfort and relief from GERD is a "one-off" surgery without pain or discomfort, that works completely to suppress any and all stomach reflux of acid, food, and bile - forever. I know my surgery was far from painless. At least the "pain" eventually brought me a significant "gain" in my overall quality of life.

I hope everyone at this forum is able to achieve a similar "gain" in their overall quality of life by finding a solution that works for them.

Post Edited (JohnnnyRebel) : 2/5/2014 9:14:58 PM (GMT-7)

Elle Jay,

No insult is intended here. But, I think your perspective regarding Doctors and Surgeons is a bit naive.

For what it is worth, in my humble opinion, there are today too many "mediocre" surgeons performing Nissen Fundoplication Surgery; the majority of whom are practitioners of the Floppy Nissen Fundoplication Procedure.

Generally speaking, a Laparoscopic Nissen Fundoplication (LNF) is a very specialized procedure that requires a surgeon to posses a specific set of surgical skills to perform correctly. And, in my opinion, the "Floppy" Nissen Fundo Modification was primarily developed so that a larger number of surgeons (many who were not necessarily the "top" or most skilled surgeons in their field) could perform gastric fundoplications with some degree of success - a success that many times eluded them with CNF surgery. Sadly, LNF Surgery has become more of a "commodity" and less of an "art form" for excellence.

Classic Nissen Fundoplication (CNF) surgery requires a surgeon to posses a higher set of surgical skills to perform correctly; and is often beyond the competence level of the average bariatric surgeon. During CNF Surgery, if the surgeon does not get the tightness of the fundus wrap around the esophagus exactly correct, the patient can forever have difficulty not being able to belch gas or swallowing food - thereby requiring a "redo" surgery to eliminate these undesirable side effects. My surgeon did a great job. I was able to "belch" gas immediately after my CNF surgery; and, frankly, I think this is not too much to expect from a competent surgeon who knows what he is doing.

Floppy Nissen Fundoplication (FNF) Surgery, on the other hand, is a more "forgiving" procedure that requires moderate skill and precision by the surgeon (who is in some cases a mediocre talent, at best). Getting the tightness of the fundus wrap around the esophagus exactly correct is no longer an issue because the "Floppy" Nissen wrap is very loose with a generous margin for error. According to documented studies, "gas bloat syndrome" is a permanent side-effect more closely associated with complete "mobilization" of the stomach fundus, as is typical during FNF surgery. If the floppy wrap is too "wide" and poorly sutured to the cardia, the "hour-glass effect" is a possible complication; where, during a bout of vomiting or severe retching, 50 percent of the stomach is "jerked" upward through the wrap. Emergency surgery is needed to correct this complication.

Yes, certainly, medical science and technology have advanced over the past several years. The introduction of laparoscopic surgical techniques more than 20 years ago has helped improve outcomes for many categories of surgery including the CNF. But, to date, there has been no new development that will equal or surpass the quality and durability of the "Classic" Nissen Fundoplication (CNF) Anti-Reflux Valve.

FOR THOSE PEOPLE WHO ARE PROPER CANDIDATES FOR NISSEN FUNDO SURGERY: When done correctly by a highly skilled and experienced surgeon, the "Classic" Nissen Fundoplication Precedure (featuring the longer, stronger, and mechanically superior sphincter muscle valve) is the most effective, durable and permanent solution to GERD available today.

Elle Jay, if you believe the "modifications" to Doctor Rudolph Nissen's Original Gastric Fundoplication Surgery were made by a group of altruistic and compassionate surgeons who were only thinking of enhancing patient welfare by delivering improved quality, you are living in la la land. This is about "money," and about some members of the brotherhood of bariatric surgeons who have, unfortunately, put their own self-interest above the patient's need for the best chance at long-term success. The most professional of practitioners want a "once-and-for-all-time" surgery; and cringe at the thought a patient needing a "redo."

Recent surgical modifications were made to the CNF primarily so that this newly created large pool of "mediocre" bariatric surgeons (who couldn't “cut it” performing CNF's) could ply their trade to larger and larger groups of poorly informed patients.

Instead of well informed and knowledgeable people insisting on the increased availability of highly skilled surgeons who are proficient in CNF Surgery; the poorly informed general public has in many cases “lowered the bar.” They have done this by embracing a procedure (e.g.“Floppy" Nissen) that is EASIER for a large number of "average" surgeons to perform, with LESS THAN SUPERIOR QUALITY results. Short FNF surgery produces an anti-reflux valve that is much weaker and less durable {with approximately 50 percent less sphincter muscle mass than Doctor Nissen specified in his original "break-through" stomach fundoplication procedure}.

I am not implying that every Short Floppy Nissen Fundo surgery performed is bound to "fail" at some point in the future. I am saying that the surgical community, as a whole, can do better by closely following in the footsteps of renowned surgeon par-excellent - Doctor Rudolf Nissen. We can do better if "we the people" hold today's brotherhood of bariatric surgeons to a higher standard of excellence. There are numerous former patients of Doctor Nissen, living and deceased, who are a testimony to his genius. Why should anyone settle for less?

NOTATION: When confronted with the issue of durability and strength of the newly created anti-reflux valve, the surgeon who is a strong proponent of the Short Floppy Nissen surgery will state that the original Classic Nissen Fundo surgery {with a longer & tighter wrap and more sutures at the "union"} can cause more pronounced dysphagia. But, when CNF surgery is done correctly, difficulty swallowing food usually abates within 6 months post-op.

For the patient who wants the most durable, permanent, and worry free Nissen fundo wrap; CNF surgery is the best choice - when performed by a surgeon who has a track record of successfully completing CNF's without long-term side effects.

Interestingly, there is another modified version of the original Nissen Fundoplication being performed overseas called the "Long Floppy Nissen." This wrap is 5 centimeters long and often includes 5 sutures at the loosely joined "union"; with complete "mobilization" of the stomach fundus from the spleen.



JohnnyRebel

Post Edited (JohnnnyRebel) : 2/6/2014 9:29:18 AM (GMT-7)

komiksowy

Welcome to Healing well and the Wrapped Club!

The nausea is quite common and will eventually go away, but getting some anti nausea meds is a good idea to have on hand to keep from dry heaving. Also your meals should be about 1/4 to 1/2 cup 4 to 8 times a day. the smaller amounts will help the nausea some and the frequency will help get enough calories into your body.

You are also experiencing "dumping". This happens when your digestive system isn't happy. Basically eating soft foods and your body healing causes food to go through you much faster than normal. this is also why frequent meals are good. when you dump your body doesn't absorb all the nutrients.

I used imodium AD, but any anti D should help along with more fiber when you can. This can also happen when eating sugary foods and will get better with time.

Now for the "time" issue....This is a marathon recovery. Expect some sort of strange symptoms to be possible for at least 6 months and more likely up to a year. You body has to heal and also adjust to it's new design.

You are very early in your recovery. Be patient and ask all the questions you need to.

Take care,
Bill

komiksowy

At 6 weeks you should be okay for light exercise and swimming. Just listen to your body and go slow. your body will let you know if you are going to fast.

Take care,
Bill

Diaba,

During multiple discussions with my laparoscopic CNF bariatric surgeon {while I was in the hospital recovering from the procedure} it was made clear to me that because I was able to "belch" stomach gas through my esophagus, I would be able to "vomit" if I ever had food or alcohol poisoning in the future. And, my surgeon told me that there were multiple sutures of high-strength braided polyester holding my wrap together, and that vomiting or severe retching would not harm the wrap because he was an expert in suturing technique.

My "real world" experiences over the past 16 years have convinced me that my surgeon was not lying to me. Believe me when I tell you that starting on day number #1 and continuing during the entire life-span of my wrap, I subjected it to numerous "high-stress" situations without any harmful effects or damage. This is the mark of true "craftsmanship" by my surgeon.

In answer to your question, based on my own experience cited above, I would expect it to be entirely possible for you find a CNF surgeon like mine who could construct a new sphincter muscle valve strong enough and durable enough to withstand any stresses that would be seen; no matter the healing time required by your body.

My CNF surgery healed well, little bit by little bit. By 6-7 months post-op., the healing process was such that I could eat or drink anything I desired at any time of day or night {including steak, potatoes, beer, wine, chocolates, onions, tomato and orange juices, fizzy soft drinks and doughy breads like bagels}. My stomach digested food and drink post-op just as efficiently as when I was a small child. I felt like I had been given a new stomach!

And, I will add that I am delighted my surgeon did not use silk or nylon sutures because within one year these materials lose 100 percent of their tensile strength and can therefore "fail" when stressed. On the other hand, for example, size "0" braided polyester sutures such as "Ethibond Excel" {the personal favorite choice of my own surgeon in CNF surgery} maintain their full tensile strength {in excess of 60,000 lbs. per square inch} indefinitely, in vivo. Cardiac surgeons use braided polyester sutures in open-heart repair and other cardiovascular procedures. NF surgery patients deserve this same high quality and robustness in suture material as is provided by cardiac surgeons in cardiovascular procedures. A CHAIN IS ONLY AS STRONG AS IT'S WEAKEST LINK.

Thanks to teaching surgeons Philip Donahue and Steven DeMeester, who are the chief architects and promoters of the Short Floppy Nissen Fundoplication Wrap; it is somewhat difficult for patients today to find highly trained and skilled surgeons who practice true Classic Nissen Fundoplication Surgery. It is sad that these two gentlemen, IN THEIR RUSH TO JUDGMENT, "foisted" onto a large portion of the bariatric surgical community, modifications to the Classical Nissen Fundoplication procedure - based solely on their own personal theory {WITHOUT SCIENTIFICALLY CONDUCTED INDEPENDENT CASE AND CONTROL GROUP TESTS WITH RADIOGRAPHIC DOCUMENTATION about the causes of long-term post operative dysphasia, or same scientific tests with radiographic documentation about the long-term post operative inability to belch trapped stomach gas}. Frankly, it is shocking that this policy of implementing and promoting wide scale use of modifications to established and proven classical NF surgical procedures {based on "guess work" instead of "real science"} has been left unchallenged by the bariatric surgical community at large. It seems to me this issue has become political in nature.

Doctors Donahue and DeMeester theorized that the length of the wrap and the tightness (issues never addressed separately)were the chief cause for these two above mentioned undesirable "after effects" of CNF surgery. They left unaddressed the issue of skill set and competence level of the surgeon performing the tight and long CNF wrap. And, this "theory" by these two surgeons promoting their short and floppy NF modification flies in the face of the successes enjoyed by hundreds of patients treated with "tight" and "long" gastric fundal wraps created by Doctor Rudolf Nissen himself. It flies in the face of the successful results of my own and many other more recent CNF surgeries. If the Donahue and DeMeester theory was correct, each and every "long" and "tight" Nissen Fundoplication wrap (CNF) would be riddled with undesirable and permanent "after effects" and would necessarily be judged a "failure."

Diaba, I hope you have similar good luck in finding a talented surgeon who uses excellent surgical technique and the correct suture material. At this time, you seem to be favoring CNF surgery.

Although I have a strong bias toward the CNF procedure in lieu of all others, in my mind, the length of the wrap {preferably 4 centimeters or longer} and number of braided polyester fundal union sutures {3 or more} offer the greatest but certainly not the only chance for obtaining a stout and durable new sphincter muscle reflux control valve. Through discussions with other members here, I recently gained some degree of respect for both short floppy Nissen surgery and long floppy Nissen surgery - where the number of sutures used and the suturing technique appear to have been adequate in each case.

As I have stated before, many variables impact the strength, durability, and permanence of a NF surgical procedure - in those cases where a 360 degree wrap is appropriate. In my opinion, these variables include but are not limited to the surgeon's correct identification and isolation of the stomach fundus, the surgeon's expert suturing and knot tying technique, the correct size {2-0 or 0} braided polyester suture materials being used, and properly anchoring the wrap to the cardia {not the diaphragm} with shoulder stiches. One of the benefits of having a "tighter" CNF wrap is greater reflux stopping power.

Whatever your choice, I hope you heal well and have a high quality "life-time" result; without any need for "NF re-do surgery." I wish the same for all of those who come here seeking advice and support through the brotherhood of common cause.


Respectfully,

Johnny R.

Post Edited (JohnnnyRebel) : 7/6/2014 8:41:29 AM (GMT-6)

Hi Lovehols,

Welcome to the Healing Well Wrapped Club! If your barium swallow indicates a too-tight wrap, it would explain some of your swallowing issues. If your surgeon thinks it would be beneficial, he/she can dilate it, to loosen it up a bit.

As far as vomiting goes...yes, you are right that vomiting is to be avoided. However, it's more likely that you retched the food up from your esophagus, rather than your stomach. It is compared to a cat coughing up a hairball.

If you did actually vomit, if it wasn't repeated retching and vomiting over a period of time, it's unlikely that you've damaged the wrap. The pain/discomfort is simply a reaction to the assault on your still healing tissue. This will resolve with time, and you'll get feeling more comfortable. It's likely there will be some residual swelling, so your swallowing will be affected for a while.

At five weeks post-op, you're in the early stages of healing. In fact, it's likely that the tightness of your wrap will resolve to some degree on its own given healing. Your surgeon will have a better idea about that.

This surgery takes six months for most of the healing and a year for the rest. I found improvements well into the second year. It's not a bit uncommon for surgeons to play down/underestimate the challenges of recovery. I don't know if this is out of ignorance (they don't tend to see the long-term recovery, as they release their patients after a last visit fairly early on), or they don't want to scare of their patients.

It is important to take small bites and chew, chew, chew your food until it basically disappears into a liquid consistency. As far as travel goes, you'll have to choose your food carefully. It'll be a trial and error experience. Keep a paper napkin handy to deposit foods that don't chew to a liquid. Keep your bites small, and chew your foods thoroughly. Bread, hard meats, noodles that aren't well-cooked should be avoided.(I found rice noodles to be hard to chew throughly in the early stages, so Pad Thai was a problem. It was a favorite of mine, so that was sad, but once healed, I had no problems with it.)

If you can surrender to your recovery and follow its lead you'll do fine. Give your body the time it needs to heal, and go with the flow. I recommend you get your doctor to prescribe anti-nausea medications if you don't already have them. I find the most effective when faced with food poisoning or a stomach bug to be Compazine suppositories. Zofran is an oral med that works well on more mild nausea. As you have been made aware, vomiting isn't good for your wrap. I carry anti-nausea meds in my purse, just in case. I am actually recovering from a stomach bug right now, and the meds have kept me from vomiting.

Hang in there...it gets better! You're right, though, it's not an easy recovery. It's all worth it in the end, though!

Happy healing,
Denise

Hi Julio,

Welcome to the Healing Well Wrap Club! Sorry to hear you're having problems.

I'll do my best to answer your questions the best I can.

1. is it possible my wrap may have come undone?

It is always possible that a wrap can be damaged or become looser. Repeated, violent vomiting can definitely do damage. It is always recommended that people who've had a Nissen always have anti nausea medication to avoid repeated retching and vomiting.

I had my Nissen about the same time as yours (Feb. '09), and have vomited three times since my surgery. Each time I used anti-nausea meds (specifically, Compazine suppositories) after a single episode of vomiting. Thankfully, the medication protected my wrap from further vomiting. If you don't have anti nausea meds always on hand, I would recommend that you do.

2. Should I seek another doctors opinion?

Not knowing the experience/reputation of the surgeon/GI docs, so it's hard to answer this one. Generally, though, I think that second opinions can be very helpful...especially when making challenging decisions. I think I would do it if I was unsure.

3. Can the new LINX procedure help me ?

I don't know much about the LINX procedure, but there are others here who are much more knowledgeable about it. From my understanding, it's not possible to do the LINX after Nissen, but I could be wrong.

4. can the nissen be re-done?

Yes, the Nissen can be redone. It is important to select a surgeon who is a highly skilled and experienced surgeon who has done many Nissen surgeries and Nissen redos. In fact, in most/many cases, the redo can still be done laproscopically. Redo surgery is more complex than the original (fairly complex) surgery, so you'll want the very best surgeon you can find.

If you find a great Nissen/redo surgeon for your second opinion, he/she will be able to determine the condition of your wrap and whether or not you need a redo.

Good luck with your search for answers!
Best wishes,
Denise

Raman:

This is a question best answered by your surgeon.

Sharon

Raman:

Absolutely, most people experience nausea and were given medication to take from their surgeon - I took Zofran and it worked. Cyclizine is basically an antihistamine that is used for nausea, if it isn't working you need to contact your surgeon about other options. You are very early into your recovery and will likely experience a lot of different symptoms and have ups and downs in your recovery, I felt the most improvement about 6-months post-surgery and back to my "new normal" at around the year mark. Have you had a follow-up appointment with your surgeon?

Sharon

Hi Raman,

A belated welcome to the Wrapped Club! You've been through major surgery, and your stomach has been traumatized...stretched, wrapped, and stitched. It's common to have stomach irritation/nausea. SharonZ has given you great advice! Zofran is a good option for that kind of nagging nausea you're describing.

I'll add one more recommendation, since you're seeing your surgeon soon. Ask him/her (or your PCP) for a prescription of both Zofran (it's has a generic equivalent) and Compazine suppositories. The Compazine is for that dreaded stomach bug that hits suddenly and causes you to retch/vomit. It's very important to protect your wrap from that type of stress on the wrap. You will want to avoid retching/vomiting (some can't--I could), which can damage the wrap. I always keep Zofran and Compazine handy, in case I get a vomiting virus. It has happened three times since my surgery in 2009, and each time was a sudden onset.

This surgery takes six months for most of the healing and a year for the rest. I even found improvements into the second year. Try to be patient and baby your stomach when it's complaining with nausea. Are you able to take PPIs or Zantac? In my case, nausea was helped by reducing acid. Just a thought.

Good luck and best wishes!
Denise

Hi Raman,

You're communicating just fine! You don't need acid reducers if your nausea isn't bad. I just suggested it as a possible option to help you.

You're not vomiting stuck food. You're more coughing it up. It's not the same thing. I don't know if you're familiar with this term, but it's more like a cat that coughs up a hairball.

You need to take small bites and be sure to chew, chew, chew your food until it is a creamy liquid consistency. If food is still getting stuck regularly, you're either not chewing your food thoroughly, are eating the wrong things too soon (un-toasted bread, meats like steak that don't chew to a liquid, etc.) or your wrap is too tight.

You're only a month into a recovery, and that's a very early stage of your recovery. Your wrap will relax over time, and although you'll always need to chew your food thoroughly, it will be far less likely to get stuck. Be very careful to choose foods that are easily chewed to a liquid. Have some room temperature liquid available to drink and swallow if you notice something that is "stuck". Try to relax and don't panic. Unless you've eaten something totally inappropriate, whatever it is will make it through your wrap with the swallowing of sips of water or tea.

Try to hang in there! It will get better!
Take care,
Denise

I realize this post was started years ago, but I was searching this topic and came across this site. I had a Nissen in 1998. The night of my surgery, they gave me codeine which I did not know I was allergic to. I ended up retching hard every 20 minutes ALL NIGHT LONG. They gave me shots, suppositories and medications in my IV. Nothing made me stop. Nothing ever came up, of course. I asked over and over again if that could have ruined the surgery and everyone told me "no". How could it NOT hurt it?? Of course, my reflux was back not long after that and got worse and worse. I now take Nexium every day.

As an aside, about 6 months after my surgery, I started having nausea after eating and lost a lot of weight as I was unable to eat. My gastric motility was extremely slow. (Before that, I had extremely fast motility and dumping syndrome from having my gallbladder out in 1996.) Nobody could figure it out. They put me on tons of medications and did lots of tests. I asked if a nerve could have been damaged or something to cause that during surgery. They told me "no" again. After about a year of that, I started getting back to normal.

One thing that made me start researching this is I was told I had a hiatal hernia before my Nissen and they were supposed to fix that too. When she got in there, she said she saw no hernia. Odd. For the last couple years, I have been having what I can only describe as a squeezing feeling around the bottom of my rib cage on the left. It is uncomfortable but not painful. It feels like someone is wringing my innards out. Strangely, it comes on a lot of times after I have worked at my computer for hours and my back is hurting. I have wondered if it has something to do with a hernia and I asked my family doctor where a hiatal hernia is one time and he distractedly pointed to that area. I really never knew Nissens could fail until I started Googling tonight.

I thought maybe it could be adhesions from the surgery and then that led to reading about Nissens failing. I have had my gallbladder out and the Nissen both laparoscopically and then 3 C-sections. When I had my 2nd C-section, the scar tissue was so bad that it took them an hour before they got the baby out, so we know there is a lot going on in there.

I have rambled on, but I am hoping to find someone else that has had a similar experience. If you stuck with me this long, thanks for reading!

I don't know for sure but I am told that I can't vomit either. I am so glad I found this forum. I am not alone with all theses issues and the depression is real as are all of the side effects. Thanks to all who posted.