Nissen fundoplication is a surgical procedure commonly performed to address severe gastroesophageal reflux disease (GERD). This operation aims to reinforce the lower esophageal sphincter, a muscular valve between the esophagus and stomach, to prevent stomach acid from flowing back into the esophagus. While often effective in alleviating chronic reflux symptoms, a Nissen fundoplication can sometimes experience complications or lose its effectiveness over time. Patients should understand potential issues if symptoms return.
What Nissen Fundoplication Failure Means
A Nissen fundoplication fails when the surgically created wrap around the lower esophagus no longer functions as intended. The purpose of the fundoplication is to create a mechanical barrier by wrapping the upper part of the stomach (fundus) around the lower esophagus, reinforcing the sphincter and preventing reflux. This wrap helps restore the natural anti-reflux mechanism.
Failure can occur in several ways, impacting the effectiveness of this barrier. The wrap may become too loose, allowing reflux to recur, or it can become too tight, obstructing food passage. Other mechanical issues include the wrap slipping, twisting, or migrating into the chest cavity, sometimes associated with a recurrent hiatal hernia. These structural changes compromise the integrity of the repair, leading to the return of symptoms.
Key Symptoms of Failure
When a Nissen fundoplication fails, symptoms often resemble those experienced before the original surgery, but new issues can also emerge. A common indicator is the return of heartburn and acid regurgitation, which were the primary reasons for the initial procedure. This happens when the compromised wrap can no longer effectively prevent stomach contents from flowing back into the esophagus.
Difficulty swallowing, medically known as dysphagia, is another frequent symptom, sometimes accompanied by a sensation of food getting stuck. This can occur if the wrap has become too tight or if there is swelling or displacement in the area. Patients might also experience chest pain, which can be sharp or dull.
Nausea and vomiting, or the inability to vomit, may indicate that the stomach is not emptying properly or that there is an obstruction at the surgical site. Bloating and excessive gas, sometimes referred to as gas-bloat syndrome, can result from air being trapped in the stomach or intestines because the patient cannot effectively belch, causing considerable abdominal discomfort.
Some individuals might also experience weight loss due to difficulty eating or persistent nausea. Less common symptoms can include chronic cough, aspiration, voice changes, or recurrent sinusitis, often related to silent reflux where stomach contents are inhaled into the airways. The severity and combination of these symptoms can vary widely among individuals.
Diagnosing a Failed Fundoplication
Confirming a failed Nissen fundoplication involves a series of diagnostic tests to identify the specific nature of the problem. A comprehensive assessment begins with a review of the patient’s symptoms and their medical history, including details of the original surgery and any previous diagnostic work-ups.
An upper endoscopy (EGD) involves inserting a thin, flexible tube with a camera to visualize the esophagus, stomach, and duodenum. This allows direct inspection of the surgical wrap for signs of disruption, slippage, or inflammation.
A barium swallow study, also known as an esophagram or upper gastrointestinal series, involves drinking a liquid that shows up on X-rays, allowing doctors to observe the passage of food and identify any anatomical changes, such as a recurrent hiatal hernia or wrap migration. Esophageal manometry measures the pressure and coordination of muscle contractions in the esophagus, to detect motility disorders or assess the pressure exerted by the fundoplication wrap.
Finally, 24-hour pH impedance monitoring involves placing a small probe in the esophagus to measure acid and non-acid reflux episodes. This test provides objective evidence of ongoing reflux, even if symptoms are atypical.
Management and Treatment Options
Once a failed fundoplication is diagnosed, management approaches are tailored to the specific cause and severity of the failure. For some individuals, especially those with milder symptoms or a loose wrap, non-surgical options might be considered. These can include dietary modifications to reduce reflux triggers and the use of medications such as proton pump inhibitors (PPIs) or H2 blockers to manage acid production. These medications can help alleviate symptoms, though they do not correct the underlying mechanical issue.
For many patients, surgical intervention becomes necessary, particularly if symptoms are severe or if there is a significant anatomical defect. Revisional surgery, often referred to as a “redo” fundoplication, repairs or reconstructs the failed wrap. This procedure involves carefully dissecting the original wrap and then re-creating a new, properly positioned fundoplication.
The specific surgical technique chosen for revision depends on the type of failure; for instance, a partial fundoplication might be performed if the original wrap was too tight, or a different type of wrap may be chosen. In complex cases, especially for patients with obesity, a Roux-en-Y gastric bypass may be considered as an alternative that also addresses reflux. These complex re-operations are often performed in specialized centers by experienced surgeons.