Laparoscopic Nissen Fundoplication

Gastro-Oesophageal Reflux Disease (GORD) also known as GERD, is a chronic, often progressive condition resulting from a weak Lower Oesophageal Sphincter (LOS) allowing acid and bile to flow back or ‘reflux’ from the stomach into the oesophagus.

GORD is a common condition affecting at least 10% of the population in Western countries and is the leading physician diagnosis in gastroenterology outpatient clinics.

People experience symptoms of GORD in a variety of ways. The most common symptom of GORD is heartbrurn. Symptoms may also include regurgitation, sore throat, chest pain and cough.

If GORD is left untreated serious complications can occur such oesophagitis, stricture, Barrett’s oesophagus, or oesophageal cancer.

Some people are born with a naturally low sphincter pressure and reflux from a very early age. In adult life, reflux may be precipitated by fatty and spicy foods, tight clothing, smoking, alcohol and being overweight or obese. In pregnancy, reflux nearly always occurs due to the pressure of the baby pushing the stomach up and aiding reflux. A hiatus hernia may also be present. Under these circumstances, a small part of the stomach has ridden up through the diaphragm into the chest and this situation tends to lead to reflux. However, the presence of a hiatus hernia does not necessarily imply that reflux will occur.

Lifestyle changes
The most important lifestyle change to improve the symptoms of reflux is losing weight. If you are overweight or obese, your symptoms of reflux may well improve dramatically if you lose weight. Reducing smoking and alcohol consumption, and changing eating habits will also improve symptoms. It is important to have regular meals and to have the last meal several hours before going to bed.
Drug therapy
Drug therapy is usually very successful at improving the symptom of heartburn. Antacids neutralise the stomach acidity and will relieve relatively mild symptoms. If these fail then stronger prescription drugs may be necessary. These are known as proton pump inhibitors (PPIs). There are several different types of PPIs. These drugs dramatically reduce the gastric acid shutting it down to minimal levels, and are usually very effective at relieving heartburn.
Surgery is required if medical treatment fails to relieve the symptoms, or, if the medication satisfactorily relieves the symptoms but as soon as the medication is stopped, the symptoms recur. Under these circumstances a large number of patients prefer to go to surgery rather than take medication for the rest of their lives. This particularly applies to the younger aged patients. Those who also have a large and troublesome hiatus hernia will require surgery to repair it.

Anti-reflux surgery is performed to correct GORD and to repair a hiatus hernia if one is present. Surgery in the modern era is performed laparoscopically, using what is popularly known as the keyhole approach. The operation is performed through 5 small puncture holes instead of through a large incision.

There are two surgical options: 

→ Laparoscopic Nissen fundoplication
→ Laparosocpic implantation of LINX® magnetic anti-reflux device

In laparoscopic surgery, we use 5 small incisions, ¼ – ½”. In anti-reflux surgery, the top part of the stomach is mobilised using special instruments. This part of the stomach is then passed around the lower part of the gullet and the stomach is sutured onto itself to form a very loose 360-degree wrap of stomach enclosing the lower part of the gullet. This acts as a valve that prevents the acid contents of the stomach refluxing back into the gullet. This operation is called “Laparoscopic Nissen Fundoplication”.

Reduced postoperative pain. Following laparoscopic anti-reflux surgery you should feel abdominal discomfort for 1-2 days and minimal pain thereafter.
Shorter hospital stay. A Nissen fundoplication usually involves an overnight stay in hospital though some patients may be discharged home on the same day, while the LINX® device is more likely to be implanted as a day case procedure.
A faster return to work. Those with sedentary jobs should be able to resume work within 1-2 weeks and for heavy manual work, within 3-4 weeks.
Improved cosmetic result due to minimal scarring.

The complications of laparoscopic anti-reflux surgery are considerably less than with open anti-reflux surgery. However complications may occur as with any operation. Complications during operation may include anaesthetic complications, bleeding, injury to the oesophagus, stomach or very rarely the spleen. Complications may occur after the operation such as wound infection, although this is very rare, and chest infection.

Should it become unsafe to complete the operation by the keyhole method due to difficulties with the operation, we will need to convert to an open operation where a much larger cut is made. The usual reasons for this occurring are because it is unsafe to continue with the laparoscopic approach, usually because the vision is not satisfactory, or if complications such as bleeding do occur during the process of the laparoscopic procedure. If you have had a lot of previous abdominal surgery then adhesions may well be present in the abdominal cavity, which may make the operation difficult or even impossible. The chance of conversion to an operation in our hands however is less than 1 in 50 patients. Thankfully, I have not needed to convert anyone to date to open surgery.

Long-term side effects are uncommon. The main side effects that do occur are an increased passage of wind (flatus) per rectum. This may be a permanent situation and is called the “gas bloat syndrome”. One of the problems of inserting a valve between the stomach and the gullet is that air cannot be freely belched out. This means that the air passes through the intestines and leads to more air being produced per anus. Another side effect is that you will not be able to bolt your food. After laparoscopic anti-reflux surgery it is important to chew food completely and to eat slowly. Stomach bloating may also occasionally occur.

In the long term, some 1 in 10 patients (10%) may have recurrence of the reflux symptoms and require a proton pump inhibitor to decrease the stomach acidity or revision surgery.

Before proceeding to anti-reflux surgery, we will need to carry out a series of tests (unless your physician has already done so) in order to confirm the diagnosis of gastro-oesophageal reflux, to assess what damage this might have caused to the gullet, and to rule out other possible explanations for your symptoms or complaints. These tests include:

This test involves the passage of a camera through the mouth and down the gullet to look at the oesophagus and assess the degree of damage that is being caused by the acid.

Oesophageal manometry
This test determines how your gullet works. It demonstrates whether the sphincter between your gullet and oesophagus has broken down and it ensures that your gullet is working normally (has normal peristalsis).

24-hour oesophageal pH monitoring
In this test a fine probe is placed in the lower part of your gullet so that the amount of acid that flows into the gullet can be measured over a 24 hour period. This shows just how much acid refluxes each day. Your symptoms are examined against the reflux events to see if there is a good correlation between the two, which would then predict a favourable outcome from surgery.

Ultrasound of abdomen
Some patients complain of various symptoms, some of which may not necessarily be related to acid reflux, and could possibly be related to gallstones. An ultrasound of the abdomen can answer this question.

Before undergoing surgery you will have your blood checked to ensure that your blood count and biochemistry are normal. It is customary also to determine your blood group and have serum available should blood be necessary. You will be admitted to hospital on the day of the operation, which is then carried out under a general anaesthetic. You will not be aware of the operation being performed.

→ After the operation, you will recover in a special recovery area near to Theatre until you are fully awake before you return to the ward.
→ Although some patients may go home on the same day as their operation, most patients stay in hospital for one night.
→ If you are feeling sick after the operation, which may occur due to the anaesthetic, you will be given nil by mouth until the nausea and sickness wears off. 
→ Usually you will be drinking fluids, and perhaps a soup and ice-cream a few hours after the surgery and may start on a light diet on the first postoperative day. It is advisable to avoid bread and fizzy drinks for the first 4-6 weeks. You will often notice during the first few weeks that food tends to stick. It is very important during this early postoperative phase to eat slowly and to chew food thoroughly. It often helps to take some liquid with your food.
→ Immediately after your operation you will have 5 little patches on your abdominal wall and these are waterproof so that you may have a shower every day. You can remove these 7 days after surgery. I use stitches that are buried under the skin; these dissolve and do not need to be removed. 
→ For a few days after the operation you may need some gentle painkillers. These should not be necessary after about 5-7 days. 
→ Your anti-reflux medication should stop at the time of the operation and should not be necessary thereafter. 
→ If, when you go home, you vomit, have severe pain or severe difficulty in swallowing, you should call your doctor immediately.

The LINX® System offers a new treatment option for GORD using laparoscopy or keyhole surgery. This is a simple and potentially reversible procedure.

The LINX® System is a small, flexible band of interlinked titanium beads with magnetic cores that helps the LOS resist opening to gastric pressures, creating a barrier to the reflux of acid and bile.

Swallowing forces temporarily break the magnetic bond to allow food and drink to pass normally through the LOS. The magnets then close the LOS immediately after swallowing to restore the body’s natural barrier to the reflux of acid and bile. The LINX™ System is placed around the oesophagus just above the stomach.

The operation is performed under general anaesthesia and, in my hands, takes approximately 30 minutes to complete. Once placed, the device will begin working immediately. Following the procedure, under our consultant’s guidance, patients should be able to resume a normal diet and will typically resume normal activities in less than a week.

Unlike other surgical treatments for GORD, the LINX™ System does not involve any anatomic alteration of the stomach. Side effects are generally minimal and resolve over time. Infrequently some patients might experience difficulty with swallowing (dysphagia) and this resolves over time in the majority without the need for endoscopic dilatation.

The LINX® System reduces or eliminates the symptoms of GORD without creating undue side effects. A clinical study of the LINX® System showed excellent relief of GORD symptoms and significantly reduced levels of acid exposure in the oesophagus three years post implant.

This study also shows that two years post implant: 
→ 86% of people have completely stopped taking medication for GORD 
→ 86% of patients are satisfied with their condition. 
→ 80% of patients have a normal level of acid exposure in the oesophagus.