Transcript Nissen Fundoplication: A Primer

Nissen Fundoplication:
A Primer
Tamara Simon, M.D.
July 2004
Anatomy/Physiology
• Lower esophageal sphincter prevents reflux of
gastric contents into esophagus
– Located cephalad to GE junction
– Zone of high pressure
• Intrinsic musculature of distal esophagus in tonic contraction
• Sling fibers of cardia
• Diaphragm
• Gastroesophageal reflux occurs:
– when high pressure zone creates too low a pressure to
prevent gastric contents from entering esophagus
– when normal pressure sphincter undergoes spontaneous
relaxation
Anatomy
At-Risk Pediatric Patients
• VERY COMMON diagnosis; the vast majority of
patients do not require surgical intervention
• Risks increased in those with:
– Neurological conditions
– Chronic pulmonary disease
• Other indications:
– Failure to thrive
– Pulmonary aspiration with subsequent pneumonia and
reactive airway disease
Symptoms
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Heartburn
Arching
Gagging
Sandifer syndrome
Regurgitation of Feeds
Physical Examination
• Often unremarkable
• Check growth curves
• Check neurological examination in
particular
• Check pulmonary examination in particular
Medical Management
• Acid suppression (antisecretory)
– Antacids: Tums
– Acid blockers: Zantac
– Proton pump inhibitors: Prevacid, Omeprazole
• Gastric motility agents (prokinetics)
– Bethanechol, metoclopramide, erythromycin, octreotide
– Cisapride banned
• Frequent, small volume feeds
• Continuous feeds (gastro or jejunal)
• Thickened feeds
Preoperative Evaluation
• pH probe
– 24 hour test
– Thin catheter with implanted electrodes is placed in
esophagus
– Capable of sensing and recording changes in pH
– Total number of reflux episodes (pH < 4), longest
episode of reflux, number of episodes over 5 minutes,
extent of reflux in upright and supine positions
• Upper GI series
– Evaluates anatomy of upper GI tract
– Looks for malrotation, obstruction
– Reflux may be documented
Preoperative Evaluation:
Less Common Studies
• Endoscopy
– Demonstrates esophagitis
• Manometry
– Esophageal dysmotility are better treated with
partial fundoplications
– New to pediatrics- GI service has ongoing
study
• Nuclear medicine scan of gastric activity
Surgical Technique
• Greater curve are dissected, fundus
mobilized, left crus dissected
• Lesser omentum is opened, right crus is
dissected
• Esophagus is mobilized
• Posterior aspect of fundus is passed behind
esophagus from left to right over a length of
2.5-3 cm with 3-4 interrupted sutures
Surgical Technique
Effect of Surgery
Complications:
Immediate Postoperative
• Secondary to surgical intervention
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Postoperative ileus
Urinary retention
Wound infection
Venous thrombosis
Pneumothorax
Dysphagia
Liver trauma
Acute herniation
Perforated viscus
Complications:
Later Postoperative
• Gas-Bloating Syndrome (30% of adults)
– Due to:
• Difficulty belching
• Delayed gastric emptying due to vagal trauma
• Tendency to swallow saliva and air
– Gagging, retching, food refusal, abdominal distention
• Dysphagia (20% of adults)
• Dumping syndrome
– Wide swing in glucose due to massive discharge of
food into duodenum
• Operative failures (5% of adults)
Outcomes
• Symptom response 90-94%
• Postoperative pH probes show no upward
escape of gastric contents
• Abdominal discomfort and gagging may be
seen
• High risk population has higher risk of
complications; therefore, often Nissens are
staged
References
• Eubanks TR and CA Pellegrini. Chapter 38- Hiatal
Hernia and Gastroesophageal Reflux Disease.
Sabiston Textbook of Surgery, 16th edition, 2001,
p.755-766.
• Cameron: Current Surgical Therapy, 7th edition, 2001,
p 1411-1412.
• Di Lorenzo C and S Orenstein. Fundoplication: Friend
or Foe? Journal of Pediatric Gastroenterology and
Nutrition. 34: 117-124, February 2002.
• Aronson BS, Yeakel S, Ferrer M, et al. Care of the
Laparoscopic Nissen Fundoplication Patient.
Gastroenterology Nursing. 24(5), 231-239.
• Ed Hoffenberg, TCH Gastroenterology Service,
personal communication, 7/23/04.