I had an my first lap nissen fundoplication back in 2006. The reason for this was 25 years of heartburn and a little Barrett's esophagus and a medium hiatal hernia. This completely stopped my heartburn but the wrap slipped this year causing me discomfort. In june of this year, I had a redo of the wrap. I had a lot of shoulder and chest pain early on which seemed to get better and almost disappear. Then about 4 weeks ago, these same symptoms have come back and I am completely uncomfortable at times. I think the same thing happened. I am seeing a top surgeon who has done about 1500 of these. I think he also does the Hill Repair and now a hybrid. But I have read some reports that the probably of failure increases after each surgery.
(1) Can you replace the wrap with EsopyX?
(2) Or is it a good idea just to take the wrap down and go back on the acid reducing pills if needed? I don't think I want to chance another attempt so that is why I favor the takedown?
Although rare, a failed fundoplication can be a challenging problem for both you and your surgeon. If a patient develops recurrent symptoms after a Nissen fundoplication, I would recommend repeating studies such as a 24 hour ph probe, manometry, barium swallow, endoscopy and possibly a gastric emptying study. Most reflux patients with recurrent symptoms will have evidence of reflux on the 24 hour ph probe, but some patients may have symptoms not related to reflux.
If the recurrent symptoms are reflux related, then revisional surgery can be considered. It is essential to determine the cause of the failure and address this at the reoperation. The use of mesh at the diaphragm or the application of an esophageal lengthening procedure may be required in addition to revising the fundoplication.
In the event that you have developed recurrent symptoms after two operations at the hiatus, I would recommend a change of approach. Again, repeat studies will be required. If you have documented reflux, then I would recommend either medical therapy with high dose acid suppressing medications, conversion to a roux-en-y bypass (similar to a gastric bypass but not associated with the same weight loss) or alternatively a repair through the chest.
Esophyx has not been studied in this situation and I am skeptical that it would offer any benefit and I cannot recommend it.
Take down of the wrap would likely increase your symptoms. I would not recommend surgery to take down the wrap if your symptoms are recurrent reflux. IF you are having symptoms of difficulty swallowing, the wrap could be converted to a partial wrap.
This is a complicated problem, but I hope this helps.
I had a follow up upper GI/barium swallow about 2 weeks ago. They looked at all of the films and could see nothing that would be causing the pain. Apparently all reflux is stopped by the wrap as all signs were negative. This was confirmed at 7 weeks post 2nd Nissen operation where they said it is not worth any biopsies. I have not had a recent scope exam. But I really don't feel or sense any reflux. Could it be something is touching the diaphram and causing this pain?
A 24 hour ph probe is the definitive study to determine if your symptoms are being caused by acid reflux. Your symptoms of shoulder and back pain could be referred pain from irritation of the diaphragm. It would be unusual for the pain to be related to your operations if your Nissen fundoplication appears to be intact on imaging studies.
I would recommend that you have a formal evaluation by your physician. There are many problems that can cause chest pain and it is important to exclude other serious conditions.
Dear Dr. Roth,
If there is irritation to the diaghragm, wouldn't that mean the wrap or stomach is touching it? The pain used to go away completely for periods of time and would get intense at times. Now, it does not completely go away and get pretty intense. Could this be that perhaps when they looked at the films, it wasn't touching because it wasn't bothering me at that 'time" ? I am really in good health and have always had yearly physicals, etc.
The radiographs give a general impression as to the appearance of the anatomy. The studies are demonstrating whether the fundoplication has "slipped" or become disrupted. It is not unreasonable to repeat a test during symptoms, but it is unlikely to change significantly.
The best evaluation for complications following a Nissen includes a barium x-ray, endoscopy, 24 hour ph-probe, and manometry. Occasionally other tests such as CT scans or gastric emptying scans are necessary. Other sources of pain other than the GI tract may also need to be considered.
This can be a difficult problem and revisional surgery should only be performed if there is objective evidence of a repairable problem.