Nissen fundoplication
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220787344
2008-06-21T16:03:51Z
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[[Image:NISSEN_FUNDOPLICATION.jpg|right|frame|Diagram of a Nissen fundoplication.]]
'''Nissen fundoplication''' is a [[surgical procedure]] to treat [[gastroesophageal reflux disease]] (GERD) and [[hiatus hernia]]. In GERD it is usually performed when medical therapy has failed, but with ''paraesophageal'' hiatus hernia, it is the first-line procedure. Partial fundoplications known as a [[Dor fundoplication]] or [[Toupet fundoplication]] may accompany surgery for [[achalasia]].
==The procedure==
In a ''fundoplication'', the [[gastric fundus]] (upper part) of the [[stomach]] is wrapped, or plicated, around the inferior part of the [[esophagus]], restoring the function of the [[lower esophageal sphincter]]. This prevents the reflux of [[gastric acid]] (in GERD) and/or the sliding of the fundus through the enlarged [[esophageal hiatus]] in the [[diaphragm (anatomy)|diaphragm]]. In a Nissen fundoplication, also called a complete fundoplication, the fundus is wrapped all the way around the esophagus.
Surgery for [[achalasia]] is generally accompanied by either a ''Dor'' or ''Toupet'' partial fundoplication. In a Dor (anterior) fundoplication, the fundus is laid over the top of the esophagus. In a Toupet (posterior) fundoplication, the fundus is wrapped around the back of the esophagus.
The procedure is often done [[laparoscopic surgery|laparoscopically]].
When used as a method to alleviate gastroesophageal reflux symptoms in patients with delayed gastric empyting, this procedure is frequently done in conjunction with modification of the [[pylorus]] via pyloromyotomy or pyloroplasty.
Nissen fundoplication is generally considered to be safe and effective, with a mortality rate of less than 1%. Studies have shown that after 10 years, 89.5% of patients are still symptom-free.<ref>{{cite journal |last=Minjarez |first=RC |coauthors=Jobe BA |year= |month= |title=Surgical therapy for gastroesophageal reflux disease |journal=GI Motility online |volume= |issue= |pages= |id= |doi=10.1038/gimo56 |url=http://www.nature.com/gimo/contents/pt1/full/gimo56.html|doi_brokendate=2008-06-21}}</ref>
==Complications==
Complications include "gas bloat syndrome", [[dysphagia]] (trouble swallowing), [[dumping syndrome]], excessive scarring, and rarely, [[achalasia]].<ref>{{cite journal |author=Waring JP |title=Postfundoplication complications. Prevention and management |journal=Gastroenterol. Clin. North Am. |volume=28 |issue=4 |pages=1007–19, viii-ix |year=1999 |pmid=10695014|doi=10.1016/S0889-8553(05)70102-3}}</ref> The procedure can also become undone over time in about 5-10% of cases, leading to recurrence of the symptoms. If the symptoms warrant repeated surgery, the surgeon may use [[Marlex]] or another form of artificial mesh to strengthen the connection.<ref>{{cite journal |author=Curet MJ, Josloff RK, Schoeb O, Zucker KA |title=Laparoscopic reoperation for failed antireflux procedures |journal=Archives of surgery |volume=134 |issue=5 |pages=559–63 |year=1999 |pmid=10323431|doi=10.1001/archsurg.134.5.559}}</ref>
In "gas bloat syndrome", patients report being unable to [[belching|belch]], leading to an accumulation of gas in the [[stomach]] or small intestine. This is said to occur in 2-5% of patients, depending on surgical technique, and is commonly believed to be related to the tightness of the "wrap". Most often, gas bloat syndrome is self-limiting within 2 to 4 weeks, but in some it may persist. The offending gas may come from dietary sources (especially carbonated beverages). Another suspected cause is subconscious swallowing of air ([[aerophagia]]). If gas bloat syndrome occurs post operatively and does not resolve with time, dietary restrictions, or counselling regarding aerophagia, it may be beneficial to consider treating the condition with an endoscopic balloon dilitation.{{Fact|date=August 2007}}
In many cases vomiting may be difficult or even impossible. The operation may be used to treat exessive vomiting, however, if used to treat gastric reflux, then difficulty in vomiting may be a problem. Initially vomiting is impossible, however, over time as the wrap settles, small amounts of vomit may be produced and in extreme cases (such as alcohol poisoning or food poisoning) vomiting may be totally possible.
==History==
Dr. Rudolph Nissen first performed the procedure in [[1955]], and published the results of two cases in a [[1956]] ''Swiss Medical Weekly''.<ref>{{cite journal |author=Nissen R |title=[A simple operation for control of reflux esophagitis.] |language=German |journal=Schweizerische medizinische Wochenschrift |volume=86 |issue=Suppl 20 |pages=590–2 |year=1956 |pmid=13337262 |doi=}}</ref> In [[1961]] he published a more detailed overview of the procedure.<ref>{{cite journal |author=Nissen R |title=Gastropexy and "fundoplication" in surgical treatment of hiatal hernia |journal=The American journal of digestive diseases |volume=6 |issue= |pages=954–61 |year=1961 |pmid=14480031|doi=10.1007/BF02231426}}</ref> Nissen originally called the surgery gastroplication, but the procedure has [[eponym|borne his name]] since it gained popularity in the 1970's.<ref>{{cite journal |author=Stylopoulos N, Rattner DW |title=The history of hiatal hernia surgery: from Bowditch to laparoscopy |journal=Ann. Surg. |volume=241 |issue=1 |pages=185–93 |year=2005 |pmid=15622007 |doi=}}</ref>
==References==
{{reflist|2}}
==External links==
* [http://www.laparoscopy.com/pictures/lap_niss.html Laparoscopy teaching site] (contains surgery footage).
* [http://video.google.com/videosearch?q=Nissen+fundoplication Nissen fundoplication videos on google video]
{{Digestive system surgical procedures}}
[[Category:Surgical procedures]]
[[Category:Gastroenterology]]
[[pt:Fundoplicação de Nissen]]