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Advice required post fundoplication

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Posted 7/22/2014 2:09 PM (GMT 0)
Here goes: all advice welcome.

I had a successful fundoplication about 11 years ago. A good recovery and relief from reflux for several years. After time, reflux recurred with (more recently) mild symptoms of LPR. This has been kept in check by medication and lifestyle changes.

A visit to the doctors revealed that repeat surgery might be considered. During the subsequent hospital consultation the surgeon suggested that my current ppi dose was low and that surgery may not be appropriate but that he would initiate tests. A barium swallow/meal with provocation revealed that the wrap was still in place and reflux was not present at that time. The endoscopy also demonstrated that the wrap was still in place and that apart from some benign polyps the oesophagus was healthy.

I am now faced with the prospect of manometry and ph testing. These require that I cease medication for a period of days before testing. I believe with the current data the surgeon will already have decided that repeat surgery is not viable and the data generated will be therefore be redundant (other than telling me that I have reflux!).

So, how to proceed? The surgeon refuses to have a telephone conversation so I'd need to attend a clinic to see him. The only clinics available are after the date set for the manometry. I'm willing to put myself through the testing (and use tax payers' money - nhs) if there's any value to the process but otherwise I can't see the point!

Post Edited (Gord-on) : 7/22/2014 11:23:40 AM (GMT-6)

Posted 7/22/2014 4:52 PM (GMT 0)
not really my area, as ive not had a wrap. But sure there must be a reason this is occurring now and the most obvious i can think of is wrap is becoming loose somehow.

I would personally do the PH test to see the severity of your reflux. The only issue is that you could be refluxing silently and this could increase your risk of developing barrets( although highly unlikely). The only issue is that whether you want to do these on ppi or off ppi. If you want to redo the wrap and dont want to take ppi, then come off them to see how bad the reflux is, I would assume the surgeon would want this done before he considers surgery, if you want to take ppi long term and see how well they control your reflux then stay on the ppi when you go for Manometry. Well this i assume is how i would view the situation, you should discuss this with your surgeon but from my understanding these wraps do not last indefinitely but has a life span of 5-10 years and even some at 20 years, i would love to see a data on the distribution for fundoplication and years. I would presume it peaks at mean 10-12 years, but assume your surgeon would know for certain so its best to discuss it with him.


good luck
Posted 7/22/2014 4:57 PM (GMT 0)
also change your thread title to include the word fundoplication that may attract those members who have actually performed the procedure to give you advice too. They are in a better position than me to give you advice.
Posted 7/22/2014 5:22 PM (GMT 0)
Thanks James. You're quite right about fundoplications becoming loose over time. At the time I had my surgery there were concerns about the long term effects of ppis so surgery was a clear solution. I was led to believe that it would be a permanent fix, which of course it isn't. As anyone who's been through manometry will appreciate, it's decidedly unpleasant. I would also need to come off all reflux medications prior to testing, which would be somewhat challenging.
I can see little benefit in undergoing the process if surgery is contraindicated by the available data. I also have some concerns about the surgeon's experience of completing repairs. My understanding is that it's a more complicated operation and I suppose I'm looking for assurances that, if I were a candidate for surgery, he'd be able to complete the procedure. The current problem is one of a lack of communication: patients are expected to follow a set process without question. This doesn't sit well with my personality type! I'm equally frustrated that the surgeon refuses to talk to patients by phone; it's an attitude that I don't understand.

Thanks for your help, the topic title has been edited.

Post Edited (Gord-on) : 7/22/2014 11:25:41 AM (GMT-6)

Posted 7/22/2014 11:14 PM (GMT 0)
Symptoms commonly return after seven years as the wrap isn't as effective.
Posted 7/22/2014 11:24 PM (GMT 0)
Well, yes, I can vouch for that. Over time the wrap will relax, the question is at what point is the relaxation deemed as failure? Is it best to repair quickly or to live with the symptoms for as long as possible since subsequent repairs become technically demanding and more prone to failure.

Looking long-term might there be a solution to which extensive prior surgery is a barrier? Advice and/or opinions are sought rather than statements for which I can offer substantial empirical evidence.
Posted 7/23/2014 2:20 AM (GMT 0)
Hi Gord-on,

Sorry to hear you're having some problems 11 years post op. If you're an LPR sufferer, it wouldn't take very much reflux to get some symptoms popping. I am in favor of getting the additional testing. The only way you'll get a full picture of what's going on is to go through every procedure.

Believe me, I know how difficult those tests are. If you're getting enough reflux to make getting off PPIs problematic, it's difficult to believe that you won't have some reflux results with your 24hr pH testing. Sometimes one test doesn't catch a problem when another does.

I expect that you're right, though. Your surgeon will not be quick to do a redo surgery if things look intact. Each redo is more complex, and he/she won't want to do an unnecessary surgery. If you can control things with your lower dose PPI, and are comfortable, a surgeon is likely to hold off on surgery.

Still, I don't think that fact rules out the possible important information those other two tests might provide. Good luck making your decision. Hope you find the answer you're looking for!

Best wishes,
Denise
Posted 7/23/2014 8:56 AM (GMT 0)
Thank you Denise. It's the 'important information' aspect to these tests that make me cautious about continuing. I'm certain that the manometry test will demonstrate that my swallowing is fine, because it is; the ph test will indicate reflux. But then what? Reflux is not just objective and data driven. Testing is likely to conclude that I need acid reducing medicine - but not how much, or of what type, or when. These aspects are empirical and subjective: only I will be able to make a clear decision about these matters. Similarly, I will be advised to make the lifestyle changes that I instigated many years ago - novelties like: raise the bed; avoid trigger foods and alcohol in particular; don't eat for three hours before sleep.

My biggest concern is that at the last manometry I spent a miserable hour (it was at least that length of time) retching miserably. A decade later and it's still in my mind as a truly horrible experience but I can force myself through it if necessary. My much wider concern is what an hour's worth of retching does to the wrap and what the relative value of the information is likely to be.

I swing between decisions on the merits of the tests. Thanks for taking the time to respond. It really is appreciated.
Posted 8/18/2014 8:13 PM (GMT 0)
An update: I am now sitting with a ph monitoring sensor stuffed up my left nostril. I've had better times but I'm not uncomfortable as such.

The manometry was unpleasant but that was all. After much gagging - which was almost certainly induced by my concerns rather than the procedure itself - the catheter was inserted and the test began. I write this as an antidote to my previous description. The fundoplication meant that I didn't vomit and, more to the point, the manometry used the new high resolution technology. This means that that once the probe is in place it stays in position and there's no necessity to move it up and down to get the readings. Additionally, and this is important, the catheter is now very much smaller than it used to be. I was told that they routinely now use a paediatric catheter so it's really quite manageable. Don't get me wrong: this isn't a fun activity, it's not a day out with jelly and ice-cream but neither was it worthy of the levels of anxiety and apprehension to which I had submitted myself. My other concern, the potential of causing damage to the wrap, was airily dismissed.

Anecdotally, my experience of coming off PPIs for the last week has been surprising. Having taken a daily dose for the last five years or so I expected some rebound. The first few days were not great but apart from odd sensations I wasn't really aware of reflux during the day. Night time was more of an issue but it has had the effect of making me reduce my portion size. I have never eaten a lot in one sitting but it seems that a side plate is a reasonable amount - little and often is the key.

So, no ranitidine or Gaviscon tonight - could be rough as I'll also be sleeping flat for the first time in years - wish me luck!

Post Edited (Gord-on) : 8/19/2014 1:45:27 AM (GMT-6)

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