Nissen fundoplication a primer
This presentation is the property of its rightful owner.
Sponsored Links
1 / 16

Nissen Fundoplication: A Primer PowerPoint PPT Presentation

  • Uploaded on
  • Presentation posted in: General

Nissen Fundoplication: A Primer. Tamara Simon, M.D. July 2004. Anatomy/Physiology. Lower esophageal sphincter prevents reflux of gastric contents into esophagus Located cephalad to GE junction Zone of high pressure Intrinsic musculature of distal esophagus in tonic contraction

Download Presentation

Nissen Fundoplication: A Primer

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.

- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript

Nissen fundoplication a primer

Nissen Fundoplication:A Primer

Tamara Simon, M.D.

July 2004

Anatomy physiology


  • Lower esophageal sphincter prevents reflux of gastric contents into esophagus

    • Located cephalad to GE junction

    • Zone of high pressure

      • Intrinsic musculature of distal esophagus in tonic contraction

      • Sling fibers of cardia

      • Diaphragm

  • Gastroesophageal reflux occurs:

    • when high pressure zone creates too low a pressure to prevent gastric contents from entering esophagus

    • when normal pressure sphincter undergoes spontaneous relaxation



At risk pediatric patients

At-Risk Pediatric Patients

  • VERY COMMON diagnosis; the vast majority of patients do not require surgical intervention

  • Risks increased in those with:

    • Neurological conditions

    • Chronic pulmonary disease

  • Other indications:

    • Failure to thrive

    • Pulmonary aspiration with subsequent pneumonia and reactive airway disease



  • Heartburn

  • Arching

  • Gagging

  • Sandifer syndrome

  • Regurgitation of Feeds

Physical examination

Physical Examination

  • Often unremarkable

  • Check growth curves

  • Check neurological examination in particular

  • Check pulmonary examination in particular

Medical management

Medical Management

  • Acid suppression (antisecretory)

    • Antacids: Tums

    • Acid blockers: Zantac

    • Proton pump inhibitors: Prevacid, Omeprazole

  • Gastric motility agents (prokinetics)

    • Bethanechol, metoclopramide, erythromycin, octreotide

    • Cisapride banned

  • Frequent, small volume feeds

  • Continuous feeds (gastro or jejunal)

  • Thickened feeds

Preoperative evaluation

Preoperative Evaluation

  • pH probe

    • 24 hour test

    • Thin catheter with implanted electrodes is placed in esophagus

    • Capable of sensing and recording changes in pH

    • Total number of reflux episodes (pH < 4), longest episode of reflux, number of episodes over 5 minutes, extent of reflux in upright and supine positions

  • Upper GI series

    • Evaluates anatomy of upper GI tract

    • Looks for malrotation, obstruction

    • Reflux may be documented

Preoperative evaluation less common studies

Preoperative Evaluation: Less Common Studies

  • Endoscopy

    • Demonstrates esophagitis

  • Manometry

    • Esophageal dysmotility are better treated with partial fundoplications

    • New to pediatrics- GI service has ongoing study

  • Nuclear medicine scan of gastric activity

Surgical technique

Surgical Technique

  • Greater curve are dissected, fundus mobilized, left crus dissected

  • Lesser omentum is opened, right crus is dissected

  • Esophagus is mobilized

  • Posterior aspect of fundus is passed behind esophagus from left to right over a length of 2.5-3 cm with 3-4 interrupted sutures

Surgical technique1

Surgical Technique

Nissen fundoplication a primer

Effect of Surgery

Complications immediate postoperative

Complications: Immediate Postoperative

  • Secondary to surgical intervention

    • Postoperative ileus

    • Urinary retention

    • Wound infection

    • Venous thrombosis

  • Pneumothorax

  • Dysphagia

  • Liver trauma

  • Acute herniation

  • Perforated viscus

Complications later postoperative

Complications: Later Postoperative

  • Gas-Bloating Syndrome (30% of adults)

    • Due to:

      • Difficulty belching

      • Delayed gastric emptying due to vagal trauma

      • Tendency to swallow saliva and air

    • Gagging, retching, food refusal, abdominal distention

  • Dysphagia (20% of adults)

  • Dumping syndrome

    • Wide swing in glucose due to massive discharge of food into duodenum

  • Operative failures (5% of adults)



  • Symptom response 90-94%

  • Postoperative pH probes show no upward escape of gastric contents

  • Abdominal discomfort and gagging may be seen

  • High risk population has higher risk of complications; therefore, often Nissens are staged



  • Eubanks TR and CA Pellegrini. Chapter 38- Hiatal Hernia and Gastroesophageal Reflux Disease. Sabiston Textbook of Surgery, 16th edition, 2001, p.755-766.

  • Cameron: Current Surgical Therapy, 7th edition, 2001, p 1411-1412.

  • Di Lorenzo C and S Orenstein. Fundoplication: Friend or Foe? Journal of Pediatric Gastroenterology and Nutrition. 34: 117-124, February 2002.

  • Aronson BS, Yeakel S, Ferrer M, et al. Care of the Laparoscopic Nissen Fundoplication Patient. Gastroenterology Nursing. 24(5), 231-239.

  • Ed Hoffenberg, TCH Gastroenterology Service, personal communication, 7/23/04.

  • Login