Nissen Fundoplication: A Primer

1. Nissen Fundoplication:A Primer Tamara Simon, M.D. July 2004

2. 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

3. Anatomy

4. 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

5. Symptoms • Heartburn • Arching • Gagging • Sandifer syndrome • Regurgitation of Feeds

6. Physical Examination • Often unremarkable • Check growth curves • Check neurological examination in particular • Check pulmonary examination in particular

7. 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

8. 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

9. 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

10. 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

11. Surgical Technique

12. Effect of Surgery

13. Complications: Immediate Postoperative • Secondary to surgical intervention • Postoperative ileus • Urinary retention • Wound infection • Venous thrombosis • Pneumothorax • Dysphagia • Liver trauma • Acute herniation • Perforated viscus

14. 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)

15. 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

16. 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.