Fundoplication

Surgical Treatment for Esophagitis

Intensive medical therapy will heal the vast majority of cases of gastroesophageal reflux disease (GERD) and other forms of esophagitis, 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 sphincter (LES). 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
Peptic Stricture

There are three basic types of fundoplication:

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
Nissen Fundoplication

A Nissen fundoplication is usually done via laparoscopic surgery, 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.

The effect of the procedure is the reestablishment of a functional one-way valve in the esophagus, allowing food to pass into the 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:

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 reoperations 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:

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
Hiatal Hernia

Causes and contributing factors can include:

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 described as minimally invasive surgery, bandaid surgery, keyhole surgery, or pinhole surgery.

Advantages of laparoscopic surgery versus a traditional open procedure include:

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.

Pyloric Stenosis

Symptoms of pyloric stenosis generally begin about three weeks of age and can include:

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 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.

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Links to key digestive disorder 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/education/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 Diabled 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 Education, 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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