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Nissen's fundoplication

Nissen's fundoplication is an operation designed to treat gastro-oesophageal reflux disease (GORD). It may be offered to you if lifestyle changes and medicines haven’t worked.

You will meet the surgeon carrying out your procedure to discuss your care. It may differ from what is described here as it will be designed to meet your individual needs.

Nissen's fundoplication is an operation to treat GORD. GORD is a condition in which the contents of your stomach come back up into your oesophagus. Your oesophagus is the pipe that goes from your mouth to your stomach. A muscular valve (sphincter) at the lower end of your oesophagus usually stops your stomach contents from doing this.

The contents of your stomach are acidic and can irritate the lining of your oesophagus if they come into contact with it. This can cause a burning feeling in your chest, called heartburn. GORD occurs when the muscular valve that separates your oesophagus and stomach doesn't work properly.

During Nissen's fundoplication your surgeon will wrap the top part of your stomach around the lower part of your oesophagus to create a new valve. If you also have a hiatus hernia, your surgeon may repair it at the same time. A hiatus hernia is when part of your stomach slides up into your chest through a hole in your diaphragm.

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Details

  • Preparation Preparing for Nissen's fundoplication

     Your surgeon will explain how to prepare for your operation. For example, if you smoke, you will be asked to stop. Smoking increases your risk of getting a chest and wound infection, which can slow your recovery.

    There are two ways to carry out Nissen's fundoplication. Your surgeon may use keyhole (laparoscopic) surgery or open surgery. He or she will explain your options. See our frequently asked questions for more information.

    You will have a general anaesthetic for both keyhole and open surgery. This means you will be asleep during the operation.

    If you're having Nissen’s fundoplication, you will be asked to follow fasting instructions. This means not eating or drinking, typically for about six hours beforehand. However, it’s important to follow your surgeon’s advice.

    Your surgeon will discuss with you what will happen before, during and after your procedure, and any pain you might have. This is your opportunity to understand what will happen. You can help yourself by preparing questions to ask about the risks, benefits and any alternatives to the procedure. This will help you to be informed, so you can give your consent for the procedure to go ahead. You may be asked to do this by signing a consent form.

  • Alternatives What are the alternatives to Nissen's fundoplication?

    Certain lifestyle changes can improve the symptoms of GORD. These include:

    • stopping smoking
    • losing excess weight
    • reducing your alcohol intake
    • propping up the head of your bed if you mainly get symptoms at night
    • not eating certain foods including chocolate, caffeine and spicy or acidic food

    Some medicines can also improve your symptoms. You will probably only be advised to have surgery if medicines aren’t suitable for you. This may be because they don’t control your symptoms, you don't want to keep taking them for rest of your life or they cause side-effects.

  • The procedure What happens during Nissen's fundoplication?

    Nissen's fundoplication takes between one and three hours. If you have a hiatus hernia, your surgeon will probably repair this first. He or she will then wrap the top part of your stomach around the lower end of your oesophagus to make a new valve. This is sewn into place. There are a number of techniques for the procedure but it’s similar whether you have keyhole or open surgery.

    Open surgery

    Your surgeon will make a single, vertical cut from the bottom of your breastbone to just above your tummy button. Afterwards, he or she will close the skin cut using stitches or staples. Occasionally the operation is done through a cut in your chest, but this is rare.

    Keyhole surgery

    Your surgeon will make five small cuts in your abdomen and use a laparoscope (a narrow, flexible, telescopic camera) to look inside your body. The camera sends images from inside your body to a monitor, which your surgeon will look at during the operation. Afterwards, he or she will close your skin cuts with stitches – these may be dissolvable.

    Occasionally if you’re having a keyhole procedure, your surgeon may need to convert to an open operation for technical reasons.

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  • Aftercare What to expect afterwards

    You will need to rest until the effects of the anaesthetic have passed. You may need pain relief to help with any discomfort as the anaesthetic wears off.

    How long you need to stay in hospital after your operation will vary depending on what type of procedure you have. You will probably need to stay in hospital for between two and five days if you have open surgery. This is likely to be less if you have keyhole surgery - usually between one and four days.

    You may have difficulty swallowing in the first few weeks after your operation. This is normal and is caused by swelling. To help with this, take small mouthfuls of soft or liquidised food and eat slowly. Problems with swallowing usually settle within six weeks.

    If your surgeon used clips or non-dissolvable stitches, they will be removed after about seven to 10 days. Dissolvable stitches don’t need to be removed – ask your surgeon how long it will take for them to dissolve.

    Your nurse will give you some advice about caring for your healing wounds before you go home. You will be given a date for a follow-up appointment.

  • Recovery Recovering from Nissen's fundoplication

    The time it takes to recover after Nissen’s fundoplication varies for everyone, so it's important to follow your surgeon's advice. You will probably recover more quickly if you had keyhole surgery.

    If you need pain relief, you can take over-the-counter painkillers, such as paracetamol or ibuprofen. Always read the patient information leaflet that comes with your medicine and if you have any questions, ask your pharmacist for advice.

  • Risks What are the risks?

    As with every procedure, there are some risks associated with Nissen’s fundoplication. We have not included the chance of these happening as they are specific to you and differ for every person. Ask your surgeon to explain how these risks apply to you.

    Side-effects

    These are the unwanted but mostly temporary effects you may get after the procedure, for example feeling sick as a result of the general anaesthetic.

    The most common side-effect is difficulty swallowing, which should gradually improve. You may be advised to have a liquid diet at first. Other common side-effects include bloating, abdominal pain, wind and diarrhoea, which should improve within a few weeks but can take as long as six months. You may find that you can't belch or vomit after the operation.

    Complications

    Complications are when problems occur during or after the operation. The possible complications of any operation include the following.

    • An unexpected reaction to the anaesthetic.
    • An infection.
    • Excessive bleeding.
    • Developing a blood clot, usually in a vein in the leg (deep vein thrombosis, DVT).

    If there are problems during or after a keyhole procedure, your surgeon may need to convert to open surgery. Another possible complication of Nissen's fundoplication is that your stomach, oesophagus or other organs nearby, such as your spleen, could be damaged during the operation.

    You may find that the symptoms of GORD come back after the operation. This can happen for a number of reasons including the new valve loosening over time or coming undone, or because you develop a hernia. Putting on a lot of weight can also lead to your symptoms coming back. If this happens, you may need another operation.

    It’s possible that if you have very severe problems after Nissen’s fundoplication, you may need to have another procedure. For example, if you continue to have trouble eating solid food or have severe bloating, you may be offered an endoscopy. This involves swallowing a narrow, flexible telescope which is then used to stretch the lower end of your oesophagus.

    It’s sometimes necessary to reverse Nissen’s fundoplication but this is a difficult operation to carry out. Your symptoms will return if you have the operation reversed.

  • Pros and cons Pros and cons

    This information is intended to help you understand the advantages and disadvantages of Nissen’s fundoplication. Think about how important each particular issue is to you. You and your doctor can work together to make a decision that’s right for you. Your decision will be based on your doctor’s expert opinion and your personal values and preferences.

    Pros

    • Nissen’s fundoplication can improve the symptoms of gastro-oesophageal reflux disease (GORD) if lifestyle measures or medicines haven’t helped.
    • The procedure means you won’t need to take medicines to stop your stomach producing acid.
    • You’re likely to have the operation as a keyhole (laparoscopic) procedure, which means you will recover more quickly and spend less time in hospital.
    • If necessary, babies and children can also have Nissen’s fundoplication.

    Cons

    • You will need to stay in hospital for a few days after this operation. You may need to spend up to five days there if you have open surgery.
    • You may experience side-effects of Nissen’s fundoplication, such as having difficulty swallowing, pain in your abdomen (tummy) and bloating.
    • You may have complications during a Nissen’s fundoplication. These may include damage to your stomach, oesophagus or spleen.
    • The symptoms of GORD may come back after the procedure.
  • FAQs FAQs

    Can my child have Nissen's fundoplication?

    Answer

    Yes, Nissen's fundoplication can be carried out in children to treat serious problems with gastro-oesophageal reflux.

    Explanation

    Gastro-oesophageal reflux is common in babies. This is when food comes back up the oesophagus (the pipe that goes from your mouth to your stomach). Usually this is prevented by the muscular valve (sphincter) that separates your oesophagus and stomach. In babies, this may not work properly because their digestive system is still developing. It may also occur because the sphincter frequently relaxes for a short time allowing food to pass back into the oesophagus. Most babies grow out of the condition by the time they are a year old. The symptoms may also improve once your child starts eating solid food as having a mainly liquid diet (milk) can be a cause.

    If the symptoms are more serious or lead to complications, your child may have gastro-oesophageal reflux disease (GORD). Complications may include oesophagitis (inflammation of the lining of the oesophagus), slow growth and development, wheezing and a persistent cough.

    If your child has severe GORD and other treatments haven’t worked, his or her doctor may suggest Nissen’s fundoplication. This operation strengthens the valve between your child’s oesophagus and stomach. There isn’t much evidence about how effective this is, but it appears to be more successful in younger children (under the age of four).

    I've heard that I shouldn’t drink fizzy drinks after Nissen's fundoplication. Is this true?

    Answer

    Yes, you will be advised not to drink fizzy drinks for several weeks after your operation. You may continue to find it difficult to drink them in the long term.

    Explanation

    After Nissen's fundoplication, you may have difficulty belching because the valve at the top of your stomach is tighter. This can lead to a build-up of gas in your stomach, causing bloating and flatulence. This may be uncomfortable or painful. Fizzy drinks cause increased gas in your stomach so your surgeon is likely to recommend that you don’t have them for about eight weeks.

    You may have difficulty eating and digesting other foods and drinks after Nissen’s fundoplication. You will be given a diet plan to follow for a few weeks until you have recovered. Talk to your surgeon if you're not sure what to eat and drink after your operation.

    What are the advantages of keyhole (laparoscopic) surgery over open surgery?

    Answer

    Keyhole surgery has a number of advantages over open surgery. These include less scarring and a shorter stay in hospital after your operation. You will probably also be able to get back to your usual activities more quickly.

    Explanation

    During keyhole surgery, your surgeon will use a laparoscope (a narrow, flexible, telescopic camera) to look inside your body. The camera lens at the end of the laparoscope sends images from the inside of your body to a screen. Your surgeon will use these images to carry out the operation.

    One of the benefits of keyhole surgery is that you will probably be in hospital for a shorter time than if you have an open procedure. You’re at a lower risk of wound complications and so you can probably get back to your usual activities sooner than after open surgery. Keyhole surgery and open surgery are equally effective procedures.

  • Resources Resources

    Further information

    Sources

    • Open Nissen fundoplication. Medscape. www.emedicine.medscape.com, published February 2013
    • Gastro-oesophageal reflux disease. BMJ Best Practice. www.bestpractice.bmj.com, published April 2013
    • McLatchie G, Borley N, Chikwe J, editors. Oxford handbook of clinical surgery. 3rd ed. Oxford: Oxford University Press; 2007:268–69
    • Gastroesophageal reflux disease. Medscape. www.emedicine.medscape.com, published November 2013
    • Laparascopic Nissen fundoplication. Medscape. www.emedicine.medscape.com, published February 2012
    • Guidelines for surgical treatment of gastroesophageal reflux disease (GERD). Society of American Gastrointestinal and Endoscopic Surgeons. www.sages.org, published February 2010
    • Richter JE. Gastroesophageal reflux disease treatment. Clin Gastroenterol Hepatol 2013; 11(5):465–71. www.medscape.com
    • Personal communication, Mr Stephen Pollard, Consultant General Surgeon, St James’ University Hospital, Leeds Teaching Hospitals NHS Trust, 2 March 2014
    • Post op fundoplication diet sheet. Living with Reflux. www.livingwithreflux.org, published February 2011
    • Disorders of infant feeding. BMJ Best Practice. www.bestpractice.bmj.com, published April 2013
    • Pediatric gastroesophageal reflux surgery. Medscape. www.emedicine.medscape.com, published October 2012
    • GORD in children. NICE Clinical Knowledge Summaries. cks.nice.org.uk, published December 2009
    • Gastro-oesophageal reflux disease. PatientPlus. www.patient.co.uk, published April 2013
  • Related information Related information

  • Author information Author information

    Reviewed by Polly Kerr, Bupa Health Information Team, February 2014

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