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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

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Nissen Fundoplication: A Primer

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Nissen fundoplication a primer

Nissen Fundoplication:A Primer

Tamara Simon, M.D.

July 2004


Anatomy physiology

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


Anatomy

Anatomy


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


Symptoms

Symptoms

  • 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)


Outcomes

Outcomes

  • 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


References

References

  • 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.


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