LAPAROSCOPIC NISSEN FUNDOPLICATION FOR REFLUX 

Heartburn

More than 44% of all adults in the United States (61 million people) experience this uncomfortable, burning sensation at least once a month. For most, it is an occasional occurrence that is easily relieved with an over-the-counter antacid. But for others, heartburn is a daily struggle that has changed the way they live their lives – from what they eat, to how they sleep, to the type of clothes they can wear.

Severe cases of heartburn may be treated with extensive drug therapy or surgically corrected. The traditional surgical procedure, known as Nissen fundoplication, involves a large incision, a hospital stay of 6 to 10 days and a recovery period of 6 to 8 weeks. As a result, surgery has typically been limited to those patients with extreme or life-threatening conditions.

Now a laparoscopic technique makes it possible to perform the same operation in a minimally invasive manner. Most patients go home in 2 or 3 days with only 5 tiny marks and, in most cases, can return to work and other normal activities within a week.

What is heartburn?

Although "heartburn" is often used to describe a variety of digestive problems, in medical terms, it is actually a symptom of gastro-oesophageal reflux disease, a condition in which stomach acids reflux, or surge upward, from the stomach into the oesophagus. Described as a harsh, burning sensation in the upper abdomen, the feeling can radiate through the chest, and into the throat and neck. Other symptoms may also include regurgitation, difficulty swallowing and chronic coughing or wheezing.

Why does heartburn occur?

At the bottom of the oesophagus there is a high-pressure zone called the lower oesophageal sphincter (LOS). The LOS acts like a valve to the stomach, remaining closed until swallowing forces the valve open.

Normally, the LOS closes immediately after swallowing to prevent reflux. When the LOS relaxes, it fails to provide adequate closure and allows stomach acids to reflux back into the oesophagus, irritating the lining and causing a burning sensation.

What contributes to heartburn?
Some people are born with a naturally weak sphincter. But for others, fatty and spicy foods, caffeine, certain types of medication, tight clothing, obesity, smoking, drinking alcohol, vigorous exercise or changes in body position (bending over or lying down) may cause the LOS to relax, causing reflux.

A hiatal hernia also is present in many patients who suffer from heartburn, although doctors agree it alone cannot cause gastro-oesophageal reflux.

How is heartburn treated?

A reflux problem has traditionally been treated in three steps: lifestyle changes, drug therapy and surgery.

In many cases, changing diet and taking over-the-counter antacids can reduce the frequency and severity of attacks. Losing weight, reducing smoking and alcohol consumption and altering eating and sleeping patterns, also can help. But if symptoms persist after these lifestyle changes, long-term drug therapy may be required.

In severe cases, drugs like Losec or Nexium may be prescribed. While antacids naturalize stomach acids, these drugs actually reduce the amount of acid produced. More aggressive treatments include Prepulsid®, a drug that strengthens the LOS and causes the stomach to empty faster.

Until recently, patients who did not respond well to lifestyle changes or drug therapy, had to either live with their condition or undergo a surgical procedure known as Nissen fundoplication. However, because the traditional "open" procedure requires a large incision and a long, painful recovery, it is generally considered a "last resort" treatment for extreme or life-threatening cases. Now, using laparoscopic techniques, surgeons can operate without a major incision.

How is laparoscopic Nissen fundoplication performed?

Nissen fundoplication involves constructing a new "valve" between the oesophagus and the stomach by wrapping the upper portion of the stomach around the lowest point of the oesophagus — much the way a bun fits around a hot dog.

In the laparoscopic procedure, surgeons use a trocar (a narrow tube-like instrument) to gain access to the abdomen. A laparoscope (a tiny telescope connected to a video camera) is inserted through the trocar, giving the surgeon a magnified view of the patient's internal organs on a television monitor.

Severe, chronic heartburn can now be surgically corrected via a minimally invasive procedure that secures the top of the stomach around the bottom of the oesophagus (inset) to prevent the reflux of stomach acids.

Four additional trocars are inserted to accommodate special instrumentation. The surgeon pulls the liver back to expose the junction between the stomach and the oesophagus, and the vessels surrounding the stomach are sealed using an instrument such as the Endo Clip* II applier or a harmonic scalpel. After the vessels are cut, the upper portion of the stomach is then wrapped and sutured around the lower end of the esophagus.This produces a new valve. At the same time the hiatus is repaired so as to cure any associated hiatus hernia.

Following the procedure, the small incisions are closed with a dissolving stitch. Within a 12 months, the incisions are barely visible.

Is Nissen fundoplication surgery effective?

Open Nissen fundoplication was introduced by Dr Rudolph Nissen in 1951. Studies have shown that more than 90% of patients who undergo the procedure say their symptoms are cured or improved after 10 years. Many surgeons familiar with both approaches believe that the long-term results will be just as good with the laparoscopic approach because the actual fundoplication is performed in exactly the same manner.

What are the advantages of the laparoscopic method?

By operating through 5 tiny openings instead of the traditional 6- to 10-inch incision, most laparoscopic patients experience less pain, less scarring, a shorter hospital stay and a quicker recovery than patients undergoing the open procedure.

How long will I be in the hospital?

In most cases, patients leave the hospital 2 or 3 days after laparoscopic Nissen fundoplication. This compares with a 6 to 10 day stay following the traditional procedure.

When can I go back to work?

Most patients can return to normal activities within a week following the laparoscopic procedure although vigorous exercise and heavy lifting should be avoided for 2 months to allow the hiatus to heal. Patients undergoing the traditional procedure usually resume normal activities in 6 to 8 weeks.

Should I be concerned that the laparoscopic technique is new?

Laparoscopy has been used in gynaecological surgery for nearly 3 decades, and today, more than 85% of all gallbladder surgery is performed laparoscopically. More recently general and thoracic surgeons have applied the laparoscopic technique to a broad range of surgical procedures including appendectomy, hysterectomy, and lung and bowel surgery.

What are the side effects and what can go wrong?

The procedure is generally safe and there has been a low or zero mortality is most experienced surgeons hands.

Side effects include:

Complications include:

The incidence of serious problems is very small and patients in the vast majority of cases very happy with the outcome of their surgery. If anything goes wrong at surgery the patient may require an open procedure, laparotomy, to repair the damage.

However, it is important to remember to ask your surgeon before undergoing any type of surgery — whether laparoscopic or traditional — about his or her training and experience.

Am I a candidate for laparoscopic Nissen fundoplication?

Although there are many advantages to laparoscopy, the procedure may not be appropriate for some patients, including those who have had previous abdominal
surgery or who have some pre-existing medical conditions. A thorough medical evaluation by your personal physician in consultation with a general surgeon trained in laparoscopy, can determine if laparoscopic Nissen fundoplication is an appropriate procedure for you.