In my early days in the surgical gastroenterology department, a patient visited our outpatient area complaining of intense burning sensations in the throat. While my consultant gathered a detailed medical history from the patient, I had the chance to glance at the patient's recent medical records. Among them was a chest X-ray that caught my attention. Excitedly, I showed it to my consultant, eager to learn more about interpreting medical images.

With a keen eye, my consultant swiftly identified and explained the telltale signs of oesophagal narrowing present in the X-ray. It felt akin to unravelling hidden clues within a mysterious puzzle. His expertise transformed that static image into a vivid insight, revealing the nuances of the patient's condition. This fascinating experience sparked my interest in the intricate details of diagnosing and understanding oesophagal disorders, showing me the importance of careful examination and interpretation in medical diagnostics, particularly for procedures such as “Nissen fundoplication,” which may necessitate surgical intervention.

What is Gastroesophageal Reflux Disease (GERD)?

GERD¹ is a condition wherein stomach acid flows back into the oesophagus. Ordinarily, after consuming a meal, food travels down the oesophagus into the stomach. The lower oesophagal sphincter (LES), a ring-like muscle located at the bottom of the oesophagus, acts like a one-way valve, allowing food into the stomach and closing to prevent the backflow of food and stomach acid.

However, in individuals with GERD, this muscle may not function properly or relax too frequently, allowing stomach acid to flow into the oesophagus. Acid reflux can cause a variety of symptoms, such as heartburn, characterised by a burning sensation in the chest. Additionally, regurgitation is the bringing up of acidic or bitter-tasting fluid into the throat or mouth. In some cases, GERD can also lead to difficulty swallowing or a sensation of a lump in the throat.

How is GERD caused?

The causative factors that lead to lower esophageal sphincter relaxation or weakness causing GERD, include:

• Smoking
• Obesity
• Pregnancy
• Consuming fatty foods
• Going to bed immediately after heavy meals or binge eating
• Hiatal hernia²
• Long-term use of painkillers
• Certain types of sleeping pills
• Antidepressant medications

What are its symptoms?

• Burning sensation in the throat
• Chest pain
• Difficulty in swallowing
•  Disrupted sleep
•  Regurgitation of food
•  Abdomen pain
•  Bloating
•  Vomiting
•  Burping

How is the Nissen fundoplication surgery performed?

The Nissen fundoplication surgery involves making small incisions in the abdomen to access the stomach. The surgeon then wraps the upper portion of the stomach around the lower part of the oesophagus to reinforce the valve between these two organs. This wrapping helps to prevent stomach acid from flowing back into the oesophagus, thereby reducing symptoms of acid reflux.

By doing this, the surgeon aims to create a stronger barrier to prevent stomach acid from returning to the oesophagus. This helps to reduce symptoms like heartburn and acid reflux that are commonly experienced with GERD.

Types of Nissen fundoplication?

1. Partial Nissen fundoplication: During a partial Nissen fundoplication, the surgeon partially wraps the upper portion of the stomach around the lower oesophagus, creating a stronger valve between the stomach and the oesophagus. While this procedure does not fully encircle the oesophagus, it aims to reduce acid reflux while maintaining some degree of flexibility in oesophagus function
2. Complete Nissen fundoplication: A complete Nissen fundoplication involves wrapping the upper part of the stomach entirely around the lower oesophagus. This wrap is intended to create a stronger barrier against the backward flow of stomach acid into the oesophagus. Although it is more effective in preventing acid reflux, it may lead to increased difficulties with swallowing or burping compared to a partial wrap

Both types of Nissen fundoplication are designed to alleviate symptoms of gastroesophageal reflux disease (GERD) by strengthening the valve between the stomach and the oesophagus. The choice between partial and complete fundoplication depends on factors such as the patient's condition, the severity of their symptoms, and other factors that the surgeon considers before deciding the most suitable approach for the patient.

What do pre-operative tests include?

• Complete blood profile
• Barium swallow³ and x-ray
• Esophageal manometry⁴
• Wireless esophageal pH testing⁵
• Endoscopy⁶
• Fasting from food and drink after midnight before the surgery

What happens during the surgery?

The surgical approach used for the procedure varies slightly depending on whether an open or laparoscopic approach is used. In open surgery, a single large incision is made in the abdomen to access the stomach and oesophagus. The surgeon then wraps the upper part of the stomach around the lower oesophagal sphincter (LES) and secures it in place with sutures.

In laparoscopic surgery, several small incisions are made in the abdomen through which laparoscopic ports are inserted. A laparoscope, a small camera attached to a tube, is then inserted through one of the ports to provide the surgeon with a view of the surgical site. Specialised surgical instruments are inserted through the other ports to perform the procedure.

Both open and laparoscopic approaches have their advantages and disadvantages, and the choice of approach depends on the surgeon's experience and the patient's needs.

What is the post-operative care needed?

• After your surgery, it is essential to drink only water for the rest of the day. Avoid fizzy drinks, as they can hinder burping, making it difficult or even impossible after the procedure
• The day following your surgery, you can begin a liquid diet. However, for the next 4 to 6 weeks, you will need to modify your food preparation. Before eating, all food should be cut into small pieces or blended into a paste-like consistency. Stick to soft, small, and frequent meals during this time
• Remember, it is crucial to eat foods that can be swallowed without any lumps. Trying to swallow large mouthfuls or inadequately chewing food could result in discomfort or the sensation of food becoming stuck, which can be quite uncomfortable

When is Nissen's fundoplication needed?

When standard medical treatments prove ineffective in relieving the symptoms of GERD, surgery becomes a recommended option. Despite efforts with medications such as antacids, H2 blockers, or proton pump inhibitors (PPIs), some individuals still experience persistent and bothersome symptoms. In such cases, surgical intervention, like Nissen fundoplication, might be advised. Surgery is usually considered when other treatments have failed to provide adequate relief, significantly impacting the individual's quality of life and potentially posing risks of complications associated with untreated or unmanaged GERD.

What are the complications after surgery?

• Difficulty in swallowing post-surgery
• Bloating, characterised by a buildup of gas in the abdomen
• Nausea, which typically subsides with anti-sickness medication
• Pain at the surgical site

Alternative treatments for GERD?

• Medications: Various medications are available to manage GERD symptoms. PPIs, H2 blockers, and antacids can help reduce stomach acid production or neutralise acid in the stomach, providing relief from heartburn and acid reflux
• Lifestyle modifications: Changing lifestyle habits includes avoiding trigger foods (such as spicy or acidic foods), consuming smaller meals, refraining from lying down after meals, elevating the head of the bed while sleeping, and maintaining a healthy weight
• Dietary adjustments: Reducing the intake of caffeine, chocolate, fatty foods, and alcohol can help minimise symptoms. Identifying and avoiding foods that worsen GERD for individual cases can be beneficial
• Positioning: Changing the body position while sleeping or lying down, such as elevating the head with pillows or using wedge-shaped pillows, can help reduce the frequency and severity of nighttime GERD symptoms
• Behavioural changes: Avoiding smoking and limiting the consumption of tobacco products can also contribute to managing GERD symptoms
• Herbal remedies and alternative therapies: Alternative therapies like herbal tea or acupuncture may provide relief for some individuals. However,  it is important to consult with a healthcare professional before using these remedies

FAQs

How long does the Nissen Fundoplication procedure take?

The surgery is performed under general anaesthesia and typically takes 1-2 hours to complete.

Can you eat a normal diet after Nissen fundoplication?

A regular diet can usually be resumed after 4-6 weeks of surgery.

What foods to avoid after Nissen fundoplication?

Immediately after surgery, fluids that are not with any gas or fizz should be consumed to avoid bloating and difficulty burping.

Can GERD return after fundoplication?

The recurrence rate is as low as 3.2%.

Who is not a candidate for fundoplication?

Elderly patients, individuals with esophageal motility disorders, those with previous upper abdominal surgery, and patients with uncorrectable coagulopathy disorders may not be suitable candidates for fundoplication.

Summary

Nissen fundoplication is a surgical procedure to address GERD. During this surgery, the upper stomach is wrapped around the lower oesophagus to prevent the backflow of stomach acid.

This surgical intervention is usually considered when medical treatments fail to control GERD symptoms. Variations in the procedure, such as partial or complete wraps, are chosen based on individual patient needs and severity of symptoms.

While generally effective in reducing acid reflux and relieving symptoms, Nissen fundoplication carries potential risks and complications, including difficulty swallowing, bloating, gas discomfort, and, in rare cases, wrap failure or persistent GERD symptoms.

Post-operatively, patients must adhere to dietary modifications, lifestyle changes, and a gradual resumption of activities to ensure proper healing and reduce complications. It is essential for patients to follow the guidance of their healthcare providers for a successful recovery.

Overall, Nissen fundoplication aims to provide relief from troublesome GERD symptoms and improve the quality of life for individuals suffering from this condition.