Nissen’s fundoplication – GOLD STANDARD TREATMENT FOR GERD
Gastro Oesophageal Reflux disease is a condition in which the contents of the stomach (Acid, food, bile) regurgitate back into the gullet (Oesophagus) causing symptoms or damage to the gullet.
It’s a common condition world over and generally about 35% of population suffer from this. 10 -15% of the population will have it bad enough to seek medical advice and testing.
Pathophysiology/ What has possibly gone wrong
In order to understand this one needs to know about the normal defense mechanisms of body that prevent reflux:
- Integrity of Lower Oesophageal Sphincter
- A snug Hiatus
- Some Intra-Abdominal Length of Oesophagus
- Angle of His
When one or more of these mechanisms are lost then one can get reflux.
Age group/Could I be born with that
Yes, one can be born with this condition. Any age group can be affected and some new born babies can have it as well. Some young children do require surgery for this as well, for most conservative measures are used. On the other end of the spectrum that may become worse or problematic in older age groups in 80 and 90 years old.
What can cause reflux in adult life
Increased weight, Increased pressure in abdomen in pregnancy or heavy lifting can be some of the reasons for contributing towards the development of this condition in adult life.
Risks associated with Reflux
Heartburn can give the following symptoms:
- Bad taste in moth
- Bad breath
- Inability to enjoy all types of food
- Sore throat
- Voice changes
- In ability to lie flat at night
- Sleepless nights
- Poor Quality of life
- Side effects of the medicine taken to help GORD
Risks and complications of GORD:
- Oesophagitis (Inflammation of Oesophagus)
- Bleeding from Oesophagus
- Sore throat
- Voice changes
- Chest pain
- Poorly controlled asthma
- Recurrent chest infections
- Stricture formation
- Barrett’s Oesophagus (change in the lining of gullet which can lead to cancer)
- Cancer of Oesophagus (this deadly cancer has low survival rate)
Assessment of Reflux:
- If one is suffering from reflux for longer than a few weeks or months, then its best to seek medical advice from a doctor.
- The doctor will try a short course of Proton pump inhibitors and reassess the situation. If the symptoms recur then a referral is done to an upper GI (gastro Intestinal) surgeon.
- Careful assessment of symptoms is done and document and appropriate investigations are carried out.
- Gastroscopy; an examination of the gullet, stomach and duodenum with a flexible telescope.
- Barium swallow; is indicated in some cases where a contrast is swallowed and x-rays are done.
- Oesophageal physiological studies may be needed for further evaluation to check the motility of the gullet and also the quantitative analysis of the severity and duration of reflux.
For occasional reflux one can use over the counter medication to manage the symptoms of reflux. This should not continue for more than a few months.
Getting advice from a doctor:
If the reflux persists for more than a few months and one is requiring to take medication to control it then it best to see a doctor for assessment and further advice.
- Clinical assessment by a specialist taking into consideration the age and exact nature of symptoms and its severity in most important first step.
- Gastroscopy (Flexible telescopic examination) may be required in some cases, depending on the age and severity of symptoms.
- Management of reflux
- Conservative and lifestyle measures
Half of the sufferers from GORD will benefit from conservative measures with occasional need of support from medical treatment. The following measures help to avoid reflux and improve quality of life:
- Losing weight
- Taking up regular exercise to lose and maintain weight and improve stomach motility
- Avoiding coffee
- Taking peppermint tea
- Eating small dry meals
- To stop smoking
- Avoiding drinking any liquid with meals
- Avoiding food aggravating the symptoms
- Citrus, Tomatoes or red wine may aggravate the symptoms
- Eating dinner at least three to four hours before going to bed
- Taking no liquid drinks before sleeping
- Some walk or gentle activity before going to bed
- Elevating the head end of the bed
- Sleeping with extra pillows
These measures can be very helpful and effective in mild GORD. If effective then variation in lifestyle is worth the effort so that medication and sny interventional procedure could be avoided.
Sometimes despite best efforts these measures may not be successful and the quality of life may remain poor. In those cases, appropriate medical treatment and medical advice should be sought. A combination of conservative measures and medical treatment may bring the symptoms under control.
If simple measures are not effective then one can use medication. These are in three categories:
- H2 Blockers
Principles of Medical treatment
Antacids are medicines in liquid or chewable tablet forms which neutralize
the acid in the stomach.
H2 Blockers or H2 antagonists work by reducing the amount of acid production
in stomach. There are three channels involved with acid production in stomach.
It tends to act on one of the three to reduce the acid secretion.
PPIs (Proton Pump Inhibitors, work by blocking the proton pump as the name
suggests, thus blocking all the three channels of acid production in stomach.
These are much stronger than the antacids or H2 blockers.
Medical control is effective in mild to moderate reflux. It’s important to continue strictly with the conservative measures as well to give the best chance to medication. Ideally one should try to use the mildest forms of medication to control the acid reflux; however, PPI’s can offer excellent control in those not responding to Antacids and H2 blockers. PPI’s have been a great success and most widely used medicines in the world for over 30 years now.
In moderate to severe cases, its likely that after initial control of symptoms the condition may worsen and may either require further courses and/or higher doses of PPIs or a combination of PPIs and H2 blockers for long term (more than 3 months). This is considered as a failure of medical treatment.
Surgery for reflux is being carried out for nearly 70 years and has stood the test of time. He oldest, commonest and most used operation today is Nissen’s Fundoplication. This is being done with minimal invasive approach, Laparoscopically for nearly 30 years. This offers the better results than another other form of operation.
There are other operations available as well and may to suitable to in some very specific situations.
The list of surgical options available for reflux treatment are:
- Nissen’s Fundoplication
- Toupet Fundoplication
- Watson’s repair
- Rossetti’s modified repair
- Lindh’s repair
- Dor Fundoplication
- Hill’s Collis gastroplasty
- Watson Mark I repair
- Watson Mark II repair
- Watson Mark IV repair
Principles of Surgical Treatments in detail
The reason for the best results and success with surgical treatment is obvious; correction of the abnormalities and restoration of the normal anatomy.
All the surgical options are based on the very well understood anatomical principals of:
- Reduction of the hiatus hernia and bringing the stomach back to abdomen from chest
- Tightening the lax hiatus (opening in the diaphragm) back to normal size
- Mobilising the oesophagus high up in the chest and bringing 5-7 cm of oesophagus back into abdomen without any pulling at it.
- Recreating the angle of ‘His’
- Making 360 degrees wrap with the fundus of the stomach, plicating the lower end of the oesophagus; fundoplication.
In experienced hands one can expect success in 96-98 % of the cases with excellent results. Short, medium- and long-term results are better than any other treatment method or surgical approaches.
The operation of Laparoscopic Nissen’s Fundoplication is probably technically most challenging operation for the surgeons to master. Appropriate training, excellent operating skills and working in high volumes centers is crucial. If a surgeon is not experienced in this procedure and has not performed a large number of these operations, then the risks of failure is high. Complications like long term difficulty in swallowing and recurrent reflux can occur.
Endoscopic TreatmentEndokinchEntryx InjectionEndostitchStretta
- Principles of endoscopic treatment
Its based on the principal that if there no hiatus hernia then reinforcing the LOS (Lower Oesophageal Sphincter) with endoscopy will control the reflux. The benefit of endoscopy is that it does not involve cuts on the abdomen. However endoscopic treatment are limited in their flexibility to achieve the correction of all the four anatomical deficits responsible for reflux like Nissen’s Fundoplication. It only focuses on just strengthening the Lower Oesophageal Sphincter (LOS) and that too is not reinforced as robustly the surgically fundal wrap around the lower oesophagus.
Operating times are similar in laparoscopic Nissen’s fundoplication and Endoscopic procedure; about 60 minutes. Both are carried out under general anaesthetic.
Overall recovery time in various aspects is similar as well.
All the endoscopic procedures to date have failed and abandoned, like Endostitch, endoKinch and Entryx injections.
Currently Stretta is used; long term results are awaited.
- Alternative treatmentList of possible treatmentsYogaAngelchick’s ProsthesisLinx procedure (Its experimental and long term results are awaited. Its correlation and lessons learned from Angelchick’s prosthesis make one worry about the complications with this technique which has limited application only)Homeopathy
There is no definite evidence of its efficacy
It has no role in managing reflux
There is no benefit, evince or scientific logic behind such therapy
May help mild symptoms and help motility of stomach
- Risks of Medical treatment
- Increased Risk of Pneumonia
- Increases risk of Cl. Difficile infection, which can be life threatening
- Osteoporosis, weak bones and fractures (hip, wrist and spine) due to poor Calcium absorption
- Anaemia due to inadequate vitamin B12 absorption
- Higher risk of developing dementia
- Increased risk of formation of polyps in stomach
- PPI users are at an increased risk of developing Chronic Kidney disease
- Acute Interstitial nephritis (AIN)
- Adverse cardiovascular events in patients taking PPIs and blood thinning agent, clopidogrel
- Slightly increased risk of spontaneous bacterial peritonitis ;especially in liver disease and cirrhotic patients
- Traveler’s diarrhoea
- Small Intestinal Bacterial Overgrowth (SIBU)
- Magnesium deficiency
- Kidney failure
Other side effects from PPIs:
- Light headedness
- Coated tongue
- Taste disturbance
- Tiredness and lethargy
- Abdominal cramps
- Increased flatulence (gas)
- Changed mood
- Suicidal tendency
- Skin rash
- Risks with endoscopic treatment
These are also an invasive procedure under general anaesthetic (GA). Risk factors of GA and endoscopy apply:
- Recurrent reflux is common
- Dysphagia (difficulty in swallowing)
- Fibrosis and shortening of Oesophagus
- Need of further treatment
- Risks of surgery
Surgery is an invasive procedure and requires a general anaesthetic. Laparoscopic surgery offers quick recovery. The risks of surgery are:
- Damage to surrounding organs
- Dysphagia (difficulty in swallowing)
- Recurrent reflux
- Reduced volume of stomach and some possible weight loss after surgery
- Gas Bloat
- Wrap slippage
- Wrap migration
- Need for further treatment
What is the Gold standard for treatment of reflux?
Gold standard for treatment of GORD is Laparoscopic Nissen’s Fundoplication. This offers better results than any other operation in terms of cure of reflux in long term; which is the whole idea for treatment in the first instance and avoidance of PPIs.
Laparoscopic Toupet Fundoplication is 2nd best option and can be used in certain situations.
Watson’s repair has a slightly higher risk of recurrence of reflux and need to restarting the medication, than the above two approaches.
Angelchick’s prosthesis was a gadget used in the last millennium and this was a soft silicone band, gently placed around the lower end of oesophagus. In theory it looked good but i a major disaster and most of these band eroded through the oesophagus and were either passed by patients in their stools or required extensive and complex surgery to retrieve. Senior surgeons having exposure to these from 90s remember the horrific tales well and avoid using any permanent prosthetic material around the oesophagus, if possible, at all.
Experienced surgeons may be skeptical with Linx (magnetic metallic beads ring placed laparoscopically around the lower gullet), for these reasons.
Professor Amir Nisar has dealt with a few of these complex cases and shred his experience and technique to deal with such complex issues, in United Kingdom, Europe and Asia on many forums.
Endoscopic Entryx injections, hailed as a “simple” treatment by injecting Entryx in the lower Oesophageal Sphincter (LOS) in early 2000’s led to huge complications and poor outcomes resulting in many complications and poor quality of life. The idea was to “beef up” the lower oesophageal sphincter with injection to regain its valve like action. This led to several problems especially severe scarring and shortening of oesophagus. Professor Amir Nisar successfully dealt with many such patients and performed Laparoscopic Nissen’s fundoplication in 2004 and 2005 in England, United Kingdom, after extensive oesophageal lengthening to gain some intraabdominal length of oesophagus.
- Authors contribution to hernia treatment at International level.
- Nearly 300 operations performed over the last 25 years.
- Professor Nisar has trained surgeons in United kingdom and mentored them to set up Anti Reflux surgery in their centers, safely
- Anti-Reflux Surgery Trial that was conducted in United Kingdom to assess the safety of Laparoscopic Anti-Reflux surgery in late 90’s. This is the largest trial of this nature to be conducted anywhere. Only very few surgeons from the United Kingdom with excellent experience, track record and good results were chosen to perform surgery on this trial. Professor Nisar was one of the surgeons selected from the country to operate in this elite group; he made a substantial and excellent contribution to trial.
- Professor Nisar has run live surgery workshops and courses in Europe and Asia to teach senior surgeons to perform anti-reflux surgery safely in their practice. He also provides advice to the surgeons who are already performing this operation.
- Professor Amir Nisar has worked in tertiary referral centres dealing with such operations in straight forward and complex cases of reflux for more than 24 years. Here he learned, gained experience and later independently dealt with complex cases referred from the other hospitals.
- The strength of Professor Nisar’s experience is not just because of his years or experience and number of surgeries; greatest understanding of the subject and technique comes from being a faculty on international scenes. Operating head to head with the best surgeons in the world has allowed him exposure to their techniques and learn and understand the best practices.
- Professor Michael Bailey and Professor Amir Nisar are the first two surgeons in the world to perform Laparoscopic Nissen’s Fundoplication as day case in Royal Surrey County Hospital, Guildford, England United Kingdom.
Patient had their surgery done, recovered and discharged on the day of the surgery. The outcomes were presented internationally in 2002 and this is a standard practice followed by many globally.
Professor Nisar has his personal innovations in the Laparoscopic Nissen’s Fundoplication:
- Amir’s Hammock Suture for liver retraction
- Amir’s wing flap
- Amir’s saddle support
- Amir’s Cruroplasty
- Amir’s Diamond fixation of the wrap
- Amir’s modified Laparoscopic Nissen’s Fundoplication