Laparoscopic Nissen fundoplication is a surgical approach to treating gastroesophageal reflux disease (GERD). This surgery aims to strengthen the weakened area of the esophagus that causes stomach acid to flow up instead of down. Nissen fundoplication surgery is designed to fix the weak area of the esophagus. The surgery is performed laparoscopically.
Few complications after a fundoplication surgery are difficulty in swallowing, esophagus sliding out of the wrapped portion of the stomach, Bloating and discomfort from gas buildup, excess gas, risks of anesthesia, risks of major surgery (infection or bleeding).
If an open surgery is done, you have to spend several days in the hospital and you may need 4 to 6 weeks to get back to your normal routine. If the laparoscopic surgery method is used, you have to stay in the hospital for only 2 to 3 days and most people can go back to their normal routine in about 2 to 3 weeks.
After your surgery, you have to follow a special diet to help prevent diarrhea, gas, and problems swallowing. You can drink clear liquids for your first few meals. Then follow a full liquid diet and then a Nissen soft diet. Eat small, frequent meals (six to eight per day). This will help you consume the majority of the nutrients you need without causing your stomach to feel full or distended. Drinking large amounts of fluids with meals can stretch your stomach.
Eat very slowly. Take small bites and chew your food well which will help in swallowing and digestion. Avoid crusty breads and sticky, gummy foods, such as bananas, fresh doughy breads, rolls and doughnuts. Sit upright while eating and stay upright for 30 minutes after each meal. Do not lie down after eating. Sit upright for 2 hours after your last meal or snack of the day.
The first bowel movement may occur anywhere from one to five days after surgery. As long as you are not nauseated or having abdominal pain, this variation is acceptable. Remember that it is very common to pass a lot more gas from your rectum; this is because you will not be able to really belch.
There are no significant restrictions on activity after surgery. You can walk, climb stairs, mow the lawn or exercise, as long as it does not put a strain on you. Returning to normal activity as soon as possible will most likely enhance your recovery. Try to avoid heavy lifting for several weeks.
Contact your surgeon immediately, if a fever arises up to 100.4 or greater, shaking chills, pain that increases over time, redness, warmth, or pus draining from incision sites, persistent nausea or inability to take in liquids.
Esophageal Manometry is a procedure which is used to identify various pathological conditions associated with the esophagus (food pipe) and lower esophageal sphincter (LES), the valve like ring of muscle, located between the esophagus and stomach. This valve is responsible in controlling the movements taking place when food bolus is passed through the esophagus to the stomach and improper functioning of it can result in condition like acid reflux or gastro esophageal reflux disease (GERD).
Patients who present with symptoms such as acid regurgitation, heart burn, chest pain (which mimic heart attack), difficulty or pain in swallowing, nausea and vomiting can be advised to go for esophageal manometry. It is also done Prior to anti reflux surgery.
Before esophageal manometry eight hour or over-night fasting is advised by the Gastroenterologist. In addition to that, a complete history including current medications and past surgical history will be taken from the patient where certain drugs like calcium channel blockers, nitrates, nitroglycerin and sedatives might have to be withdrawn for a certain duration.
Patient will be lied down on bed, and an application to numb the nasal canal (anesthetized) is applied which will help in reducing the discomfort throughout the procedure.
Thereafter, a very thin and flexible tube is inserted into the nose which will pass down the esophagus until it reaches the stomach and when it is pulled back gradually, the patient is asked to swallow at different points so that the individual pressures and tone of the esophageal muscles and lower esophageal sphincter is measured by sensors attached to the tube. This test is also used to measure the pH value of the esophageal contents with the help of the pH probe attached to the same tube.
This whole procedure takes approx 30 to 45 minutes.
It is normal that some patients may gag or feel uncomfortable when the tube is inserted initially and get a stuffy nose during the procedure. However, breathing is not interfered by the procedure.
Major complications of esophageal manometry include perforation, where a trauma to the esophagus might have caused a hole on it resulting in leakage and aspiration where an inhalation of saliva or some other contents in the stomach takes place which can give rise to pneumonia and lung injuries.
The results obtained by esophageal manometry will help to diagnose problems such as abnormal contractions of esophageal muscles, Achalasia cardia (improper opening of LES), Hiatus Hernia and GERD (weak LES), spasmodic movements of the esophagus and Scleroderma (an autoimmune condition which will paralyze muscles of esophagus).
Methods of treatment will be planned based on the type and severity of the conditions diagnosed by esophageal manometry.
Esophageal Manometry is useful test to diagnose food pipe movement and pressure disorders and is available at colorectal department of Fortis Hiranandani hospital Vashi , Navi Mumbai, headed by Dr Nitish Jhawar.
Are you also suffering from mild or severe heartburn and regurgitation which interferes with your day to day activities?
Then, you may be a victim of the commonly prevailing condition known as Gastro-esophageal reflux disease, or GERD. This occurs due to reflux of stomach acids from the stomach back into the esophagus due to lax lower esophageal sphincter (LES) located between stomach and esophagus.
Commonly experienced presenting complaints may include burning sensation in throat /Chest (Heart burn), nausea, vomiting, regurgitation, difficulty in swallowing, chronic cough with or without wheezing.
Some patients with mild GERD could be treated with life style modifications such as change of dietary pattern, usage of over the counter anta-acids when necessary, losing weight, quit smoking and alcohol, and practicing proper sleeping patterns whereas some may require medications like anta-acids which will neutralize acids, flowing back to the esophagus.
However, patients who are not responding to both these ways of treatment will require surgical interventions. The latest and the most preferred surgical therapy for GERD includes Fundoplication Surgery, which can be done either as an open procedure or laparoscopically.
As far as the technique of fundoplication is concerned, the patient will be made unconscious and pain free by administering general anesthesia. The upper curvature of the stomach also known as fundus is sutured as a wrapping around the esophagus, allowing the lower portion of the esophagus exit through a tiny canal formed by the stomach muscle.
This method will help to tighten the lower esophageal sphincter, and there by stop the back flow of stomach acids. The already damaged, or inflamed esophageal lining will heal eventually and the symptoms will improve over time.
If the patient undergoes an open surgery which generally needs a larger incision, he will be advised to stay in the hospital for a few days and can return back to routine work within 4-6 weeks whereas in the case of laparoscopic fundoplication surgery, he will be discharged within 2-3 days and can get back to day to day work within 2-3 weeks.
Most of the patients who undergo fundoplication surgery will recover completely over time while some may rarely develop a recurrence with new symptoms like bloated feeling in the stomach, flatulence and renewed heart burn which may require further medication or even another surgery. Other possible complications are a difficulty in swallowing if the stomach is wrapped too high or too tightly on the esophagus during the procedure or develop general complications of anesthesia.
However, GERD is a condition which can reduce the quality of one’s life in a long term basis due to its irritating and painful nature and therefore it is worth trying to undergo a fundoplication surgery, in case where life style modifications and medical interventions fail.
The stomach normally secretes acid that is essential in the digestive process. This acid helps in breaking down the food during digestion. When there is excess production of acid by the gastric glands of the stomach, it results in the condition known as acidity, dyspepsia, heartburn.
Heartburn is burning sensation in mid chest or throat that’s caused by digestive juice acid rising up from stomach to the food pipe or esophagus It’s a common symptom of the condition called gastroesophageal reflux disease or GERD, also called acid reflux or acid regurgitation. Occasional reflux is common , reflux more than twice a week is GERD.
Heartburn. Most likely to occur in connection with the following activities:
Eating a heavy meal
Lying down, particularly on the back
Pain and discomfort in the upper abdomen
A feeling of fullness in the stomach
Nausea after eating
Regurgitation. feeling of acid backing up in the throat. Sometimes acid regurgitates as far as the mouth and can be experienced as a “wet burp.”
Less Common Symptoms
Elderly patients with GERD often have less typical symptoms than do younger people. Most children under 12 years with GERD, and some adults, may have GERD without heartburn. Instead, they may have dry cough, asthma symptoms, or trouble swallowing
Chest pain is a common symptom of GERD. It is very important to differentiate it from chest pain caused by heart conditions.
Symptoms in the Throat-
Acid laryngitis. A condition that includes hoarseness, dry cough, the sensation of having a lump in the throat, and the need to repeatedly clear the throat.
Trouble swallowing. In severe cases, patients may choke or food may become trapped in the esophagus, causing severe chest pain. This may indicate a temporary spasm that narrows the tube, or it could indicate serious esophageal damage or abnormalities.
Chronic sore throat
Coughing and Respiratory Symptoms. Airway symptoms, such as coughing and wheezing, may occur.
Chronic Nausea and Vomiting. Nausea or in rare cases vomiting can occur.
What causes GERD?
When we eat, food travels from mouth to stomach through a tube called the gullet or esophagus. At the lower end of the esophagus is a small ring of muscle called the lower esophageal sphincter (LES) which acts like a one-way valve, allowing food to pass through into the stomach. Normally, it prevent back-flow of stomach juices (acid)) into the esophagus. GERD occurs when the LES does not function properly allowing acid to flow back and burn the lower esophagus. This irritates and inflames the esophagus, causing heartburn and eventually may damage the esophagus. Research shows that in people with GERD, the LES relaxes while the rest of the esophagus is working. There may be Impaired Stomach Function or Motility Abnormalities.About 30 – 40% of reflux may be hereditary.
What contributes to GERD?
Common foods that can worsen reflux symptoms include
drinks with caffeine or alcohol
fatty and fried foods
garlic and onions
Many other factors can also play a role in triggering heartburn and causing GERD
Overeating. Stomach remains distended when there are large quantities of food in it. The more your stomach stays distended, the more likely the LES won’t close properly. When it doesn’t close, it can’t prevent food and stomach juices from rising back up into the esophagus.
Eating habits. Eating too rapidly, eating while lying down or too close to bed time can be a heartburn trigger.
Smoking. Smoking cigarettes is another potential cause of heartburn.
Hiatal hernia. Your diaphragm is a muscular wall that separates your stomach from your chest. It helps the LES keep stomach acid where it belongs. When the LES and the upper part of the stomach move above the diaphragm you develop a hiatal hernia. The hernia makes acid reflux, which causes heartburn, more likely.
Obesity or overweight. Research suggests that being obese or overweight can be a trigger for heartburn and reflux disease.
Pregnancy. Pregnant women are particularly vulnerable to GERD in their third trimester, as the growing uterus puts increasing pressure on the stomach. Heartburn in such cases is often resistant to dietary interventions and even to antacids.
Medicines. Common medications taken for other problems can increase the likelihood of heartburn. That includes medicines used to treat asthma, high blood pressure, heart problems, arthritis or other inflammation, osteoporosis, anxiety, insomnia, depression, pain, Parkinson’s disease, muscle spasm, or cancer.
Exercise. Increased pressure on the abdomen can increase the risk of acid reflux. Weightlifters had the most heartburn and acid reflux. Runners had milder symptoms and less reflux than weightlifters.
How is GERD treated?
If you have had symptoms of GERD and have been using antacids or other over-the-counter reflux medications for more than 2 weeks visit a gastroenterologist
Depending on the severity of your GERD, treatment may involve one or more of the following lifestyle changes, medications, or surgery.
General Measures – Self-Care
Some dietary and lifestyle tips for heartburn relief-
Avoid trigger foods. Classic GERD triggers include chocolate, coffee, cols, alcohol, peppermint, citrus juices, and tomatoes. The exact food triggers vary from person to person
Don’t eat before bed. You shouldn’t eat two to three hours before bed. Not eating gives your stomach time to empty before you lie down.
Loosen your belt. Tight belts or pants can aggravate your GERD symptoms. Wear looser clothing, especially at night.
Prop up the bed. When you stick blocks under the head of your bed and raise it 6 to 8 inches, gravity will prevent the acids in your stomach from flowing into the esophagus during the night.
Lose weight. If you’re obese, aiming for a 10% weight loss is always a good idea.
Evaluate your other medications. Many common medications — aspirin and other NSAID painkillers, along with some drugs for high blood pressure — can make GERD worse.
Medications for GERD
Antacids, are usually the first drugs recommended to relieve heartburn and other mild GERD symptoms.
Foaming agents, work by covering your stomach contents with foam to prevent reflux.
H2 blockers, ranitidine decrease acid production. provide short-term relief and are effective.
Proton pump inhibitors omeprazole lansoprazole pantoprazole , rabeprazole and esomeprazole are more effective than H2 blockers and can relieve symptoms and heal the esophageal lining.
Prokinetics help strengthen the LES and make the stomach empty faster. This group includes bethanechol (Urecholine) and metoclopramide (Reglan). Metoclopramide also improves muscle action in the digestive tract. Prokinetics have frequent side effects that limit their usefulness—fatigue, sleepiness, depression, anxiety,
What if GERD symptoms persist?
If your symptoms do not improve with lifestyle changes or medications, you may need additional tests.
Barium swallow radiograph uses x rays to help spot abnormalities such as a hiatal hernia and other structural or anatomical problems of the esophagus. With this test, you drink a solution and then x rays are taken. The test will not detect mild irritation, although strictures—narrowing of the esophagus—and ulcers can be observed.
Upper endoscopy is more accurate than a barium swallow radiograph. The doctor may spray your throat to numb it and then, will slide a thin, flexible plastic tube with a light and lens on the end called an endoscope down your throat. The endoscope allows the doctor to see the surface of the esophagus and search for abnormalities.
The doctor also may perform a biopsy. The tissue is then viewed with a microscope to look for damage caused by acid reflux and to rule out other problems if infection or abnormal growths are not found.
pH monitoring examination through a small tube into the esophagus or a tiny device to the esophagus that will stay there for 24 to 48 hours. when and how much acid comes up into your esophagus is measured. This test can be useful if combined with a carefully completed diary—recording when, what, and amounts the person eats—which allows the doctor to see correlations between symptoms and reflux episodes.
Surgery For GERD
Surgery is an option when medicine and lifestyle changes do not help to manage GERD symptoms. Surgery may also be a reasonable alternative to a lifetime of drugs and discomfort. With the new minimally invasive approach, surgery is now a viable initial therapy and is safe and effective in people of all ages, including infants.
Nissen Fundoplication is surgery to repair hiatal hernia and is surgical treatment for GERD. Upper part of the stomach is wrapped around the LES to strengthen the sphincter, prevent acid reflux, and repair a hiatal hernia.
Endoscopic techniques. In one endoscopic method for treating GERD, an instrument is inserted that delivers an electrical current to the lower esophageal sphincter. This results in scarring which tightens the sphincter. In a second method, sutures are placed in the sphincter to tighten the sphincter
What are the long-term complications of GERD?
Having heartburn more than occasionally can reduce your quality of life. It can affect not just what you eat, but how you sleep and what activities you do.
Chronic GERD that is untreated can cause serious complications. Inflammation of the esophagus from refluxed stomach acid can damage the lining and cause bleeding or ulcers—also called esophagitis. Scars from tissue damage can lead to strictures—narrowing of the esophagus—that make swallowing difficult.
Some people develop Barrett’s esophagus, in which cells in the esophageal lining take on an abnormal shape and color. Over time, the cells can lead to esophageal cancer, which is often fatal.
Studies have shown that GERD may worsen or contribute to asthma, chronic cough, and pulmonary fibrosis.
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