Fundoplication
Surgical
Treatment for Esophagitis
With
intensive medical therapy, gastroesophageal
disease (GERD) and other forms of esophagitis
will heal the vast majority of cases, but symptoms often
tend to recur within one year after cessation of medication.
When it is a chronic condition, therapy involving acid
suppression or pro-motility agents may be required indefinitely.
Mucosal damage or other changes may persist despite
control of symptoms, and the long-term effect of some
medications is uncertain. Surgical treatment can be
an attractive option.
Fundoplication is a surgical procedure in which the
upper part of the stomach (gastric fundus) is wrapped
(plicated) around the lower (inferior) part of the esophagus,
restoring the function of the lower
esophageal sphincterr(LES) (link to Motility
page). The LES normally functions to allow masticated
food (bolus) to pass into the stomach while preventing
gastric contents (chyme) from returning back up into
the esophagus (reflux). Various conditions may result
in failure of the LES to allow swallowing or to prevent
reflux.
Peptic
Stricture
There are three basic types of fundoplication:
- Dor
(partial anterior) fundoplication, in which the fundus
is laid over the top of the esophagus.
- Toupet
(partial posterior) fundoplication in which the fundus
is wrapped to the back of the esophagus.
- Nissen
(complete) fundoplication, in which the fundus is
wrapped all the way around to the front of the esophagus.
Either of the two partial fundoplications are generally
used to surgically correct achalasia, a disorder in
which the esophagus has impaired muscular ability to
move the food bolus down into the stomach (peristalsis)
and the LES fails to relax properly in response to swallowing
(deglutition).
However, even if the swallowing and peristaltic functions
are otherwise normal, but the LES fails to prevent reflux
by contracting properly, a complete fundoplication may
be indicated.
It is rare for children suffering from GERD to require
surgery. They will usually respond to dietary changes
and adjustment of feeding techniques or eating habits,
but when surgery is required, Nissen fundoplication
is the most commonly performed operation.
Nissen
Fundoplication
Nissen (complete) fundoplication is a surgical procedure
used to treat GERD
and hiatal hernia.
For paraesophageal hiatal hernia it is normally the
primary treatment, but for GERD it is usually an elective
procedure after other therapy has failed.
Procedure
The goal of surgery for GERD is to reestablish the anti-reflux
barrier without creating an obstruction to the food
bolus.
During a Nissen procedure, the fundus of the stomach
(to the left of the esophagus and above the main part
of the stomach) is wrapped around the back of the esophagus.
The portion of the fundus that now comes around the
right side of the esophagus is sutured down the front
to the portion remaining on the left. This fundoplication
resembles a buttoned shirt collar, with the sutures
as the buttons, the fundus wrap as the collar, and the
esophagus as the neck protruding up through the buttoned
collar.
 Nissen
Fundoplication
A Nissen fundoplication is usually done via laparoscopic
surgery (see A Closer Look below), but is also done
by traditional open surgery. When used to alleviate
GERD it is often accompanied by modification of the
pylorus by pyloromyotomy or pylorplasty to relieve delayed
gastric emptying due to pyloric stenosis
(see
A Closer Look below).
The effect of the procedure is the reestablishment of
a functional one-way valve in the esophagus, allowing
food to pass into stomach but preventing stomach contents
from flowing back up into the esophagus, thereby relieving
GERD.
Complications
After a Nissen procedure, complications that may occur
include:
- Gas
bloat syndrome, or inability to belch leading to an
accumulation of gas in the stomach or small intestine,
caused by tightness of the wrap (plication), or swallowing
of air (aerophagia).
- Dysphagia,
or trouble with swallowing.
- Dumping
syndrome, or rapid
gastric emptying.
- Excessive
scarring.
- Achalasia
(rarely).
Risks and Prognosis
Comparative incidence of complications and failure rates
vary slightly between laparoscopic Nissen fundoplication
(LNF) and open Nissen fundoplication (ONF), but in both
cases the presence of preexisting conditions is associated
with a tendency for higher reoperation rates.
Subsets of children with increased fundoplication failure
rates include:
LNF has a shorter hospital stay and shorter time to
initiation of regular feeding than does ONF. Overall,
LNF is superior to ONF in terms of cost, patient outcome,
and acute complications. There is a somewhat higher
incidence of eventual reoperation for LNF compared to
ONF, but reoperation rates for both procedures are considered
quite low, and the procedures are considered safe and
effective.
A
Closer Look
Hiatal Hernia
Paraesophageal hiatal hernia is a condition in which
a portion of the stomach protrudes upward into the chest,
through the opening in the diaphragm, generally as a
result of a weakening of the supporting tissue.
Symptoms of hiatal hernia can include:
- Heartburn,
especially when bending or lying down
- Difficulty
swallowing (dysphagia)
- Chest
pain
- Belching
Pain and discomfort are due to reflux of gastric contents
or air, and hiatal hernia is not the only possible cause
of reflux, but reflux does happen more easily in the
presence of hiatal hernia.
Hiatal hernia may be detected and confirmed by upper
GI series, barium swallow x-ray, or esophago-gastro-duodenoscopy
(EGD).
Hiatal
Hernia
Causes and contributing factors can include:
- Obesity
- Frequent
coughing
- Straining
due to constipation
- Stress
- Congenital
weakness of the lower esophageal sphincter (LES) and
supporting tissue.
Children with this condition usually have it from birth
(congenital), and it is often associated with GERD in
infants. Nissen fundoplication is used to correct this
condition surgically, commonly performed laparoscopically,
and has low complication rates and quick recovery.
Laparoscopic Surgery
The defining element of this surgery is the use of a
laparoscope, a telescopic rod and lens system connected
to a video camera or other viewing device. An associated
fiber optic cable system channels illumination from
a cold (halogen or xenon) light source to the operative
field.
Laparoscopic surgery is also be described as minimally
invasive surgery, bandaid surgery, keyhole surgery,
or pinhole surgery.
Advantages
of laparoscopic surgery versus a traditional open procedure
include:
- Reduced
blood loss
- Smaller
incisions, with less scarring, less pain, and shorter
recovering
- Slightly
longer procedure time, but much shorter hospitalization
- Reduced
exposure to infection
Video
of a Laparoscopic Nissen Fundoplication Surgery
Pyloric
Stenosis
Infantile hypertrophic pyloric stenosis, or gastric
outlet obstruction, is a narrowing of the opening from
the stomach to the intestines, due to spasm and hypertrophy
of the muscle surrounding the pyloric antrum. This condition
is most commonly evidenced by severe vomiting in the
first few months of life.
Symptoms of pyloric stenosis generally begin about three
weeks of age and can include:
- Vomiting,
persistent or projectile, especially after feeding
- Constipation
or infrequent small stools over a couple of days
-
Dehydration, including several hours between wet diapers,
wrinkly or doughy appearance of skin, sunken soft
spot on head, jaundice
-
Failure to thrive and lethargy
Diagnosis includes a reliable and consistent history
and description of vomiting. An external physical exam
may reveal a pyloric mass, a firm moveable lump in the
belly like an olive. An enlarged, thickened pylorus
can be seen by ultrasound. Barium swallow X-ray can
reveal any narrowing or obstruction. Blood tests will
reveal electrolyte imbalances resulting from dehydration
that must be corrected.
Pyloric stenosis is typically managed with surgery by
pyloromyotomy, which involves cutting through the thickened
muscles of the pylorus to relieve the obstruction. This
is commonly done laparoscopically.
After
successful surgery, most infants return to normal feeding
relatively quickly. Because of swelling at the surgical
site, there may still be vomiting for a day or so. As
long as there are no complications, most infants resume
regular feeding and can be sent home within 48 hours.
If symptoms recur weeks after surgery, it may suggest
other associated problems such as GERD or gastritis,
or that the pyloromyotomy was incomplete.
Links
to key .org and .gov sites
Kids Health for Parents
kidshealth.org/parent/medical/digestive
NDDIFC Easy-to-Read Publications
digestive.niddk.nih.gov/ddiseases/ez.asp
NDDIFC About Kids
aboutkidsgi.org/site/about-gi-health-in-kids
North American Society for Pediatric Gastroenterology,
Hepatology, and Nutrition (NASPGHAN)
naspghan.org
NASPGHAN Public Information Links
naspghan.org/wmspage.cfm?parm1=317
International Foundation for Functional Gastrointestinal
Disorders (IFFGD)
aboutgimotility.org
International Pediatric Endosurgery Group (IPEG)
Guidelines for Surgical Treatment of Pediatric GERD
ipeg.org/guidelines/gerd.html
Citations
Collins III JB, Georgeson KE, et al. Comparison of Open
and Laparoscopic Gastrostomy and Fundoplication in 120
Patients. J Ped Surg 1995: 30(7): 1065-1071.
Curet MJ, Josloff RK, Schoeb O, Zucker KA (1999). Laparoscopic
reoperation for failed antireflux procedures. Archives
of Surgery 134 (5): 559-563
Humphrey GME and Najmaldin AS. Laparoscopic Nissen Fundoplication
in Disabled Infants and Children. J Ped Surg 1996:31(4):
596-599.
Minjarez RC; Jobe BA. Surgical therapy for gastroesophageal
reflux disease. GI Motility online.
Nissen R (1961). Gastropexy and fundoplication in surgical
treatment of hiatal hernia. The American Journal of
Digestive Diseases 6: 954-961
O’Neill JA, Rowe MI et al. Gastroesophageal Reflux.
Pediatric Surgery Fifth Edition, 1998: 1007-1028.
Rice H, Seashore JH, Touloukian RJ. Evaluation of Nissen
Fundoplication in Neurologically Impaired Children.
J Ped Surg 1991: 26(6): 697-701.
Rothenburg, SS. Experience with 220 Consecutive Laparoscopic
Nissen Fundoplications in Infants and Children. J Ped
Surg. 1998: 33(2): 274-278.
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