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Dr. Andrew Rynne

Family Physician

Exp 50 years

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How long does the wrap last in nissen fundoplication? Can another surgery be performed to tighten it?

Answered by
Dr. Deepak Kishore Kaltari

General Surgeon

Practicing since :2002

Answered : 3192 Questions

Posted on Tue, 10 Dec 2013 in Abdominal Pain
Question: Questions on nissen fundoplication: 1)i read that the wrap lasts on average 5 years.What happens after that?The wrap loosens up and then we are back on the ppi's?Can another surgery be performed to tighten it up again or is it too risky? 2)what are the odds of the wrap lasting more than 5 years and being off the ppi's longer? 3)is it true that the general success rate for the fundoplication is about 80%? 4)also the fundoplication will help with esophagus and throat but we should not expect a lot of difference in digestion from before operation correct?i.e likely will be on gerd diet for life?Assume 12-15 years of ppi's prior to operation. 5)also is having gastritis before operation making significant difference in potential success of operation or how the surgery is performed? Thx. XXXXXXX
Answered by Dr. Deepak Kishore Kaltari 7 days later
Brief Answer: low recurrence if proper case selection done Detailed Answer: Namaste Welcome to Healthcare-Magic Greetings of the day Dear XXXXXXX Before I reply to your query I would like to stress few important points about Fundoplication The success of Fundoplication surgery and post operative outcome are good if following things are followed 1. Right indication- Failure to respond to full conservative medical management and other oesophageal motility disorder ruled out. 2. Right patient selection- high incidence off recurrence in obese and patients with poor compliance 3. Right and technically correct surgery- the wrap should not be too loosening 4. Right experienced surgeon A technically right procedure done by experienced surgeon with Good patient selection with right indication, the success rate and post operative outcome and improvement are good. Coming to your query 1. The outcome of Fundoplication surgery is assessed by improvement in clinical symptoms and improvement in pathology of oesophagus in form of resolution of ulcer or inflammation. Rightly done wrap will not slip and will last longer, also clinical evidence does not suggest if if last only five years. in case recurrence does occur due to loose wrap, redo surgery can be safely be performed if the cause of symptoms are documented to be due to recurrence. 2. Properly done Fundoplication for right indication in rightly selected patient the success rate is more than 90% 3. Success rate all depends on good patient selection 4. It is important to remember that Fundoplication is basically done to strengthen the natural mechanism of preventing reflux of gastric contents into oesophagus. Lifestyle modification in form of change in eating habits, frequent and small meals, avoiding spicy/oily/carbonated beverages etc form integral part of pre and post operative management of gerd. So it would not be wrong to say that it is lifelong. 5. It is important to treat gastritis before embarking on Fundoplication. As.Presence of gastric implies inadequate tried medical management and also the symptoms of gastritis may worsen after surgery. I hope it helped Wishing you a healthy life Take care Regards Dr Deepak XXXXXXX Consultant Surgeon
Above answer was peer-reviewed by : Dr. Vaishalee Punj
Follow up: Dr. Deepak Kishore Kaltari 9 hours later
Thank you doctor.It was all worth the wait.What i read in books and internet is what you say that we try the medical management to the maximum and if it no longer works then consider surgery.My problem is i have been on 1 ppi per day for the last 15 years and about two years ago there were definite signs that they were not working well any more,i.e positive effects not as good and negative effects like fatigue and poor absorption become prevalent.And i have been an active guy all my life.I try to follow the gerd diet as best as i can but it seems like the food just goes in and goes out with no energy coming with it.Blood tests have not shown anything particularly wrong but i have lost 20 pounds without trying to lose it and i have lots of internal gases and a chronic cramp in the right side that comes out once every day sometimes after eating and other time on empty stomach. I am still losing a few pounds every month and i am convinced that if i could get off the ppi's i would regain my absorption and energy back.How long do we try more ppi's before i get too thin and questionable for surgery?Because of this absorption issue my defense mechanisms are weakening and now i have prostate infection/inflammation on top of esophagitis and lpr. And the remedy for gastritis is ppi's again i expect. Comments/suggestions?I am already on double dose of antacids 1 nexium and 2 xantac's per day.I hesitate on taking two nexiums per day because of the absorption issues. Comments/suggestions?
Answered by Dr. Deepak Kishore Kaltari 33 minutes later
Brief Answer: ppi do not cause significant weight loss Detailed Answer: Greetings of the day I hope you have already been worked thoroughly and have undergone upper Gastrointestinal endoscopy to document the severity of gastritis and to rule out active ulceration. Presence of gastric ulceration which sometime occurs due Helicobacter pylori may sometime be the cause of weight loss. Long term intake of ppi does not affect absorption of protein or fat significantly and is not known to cause significant weight loss. Avoid food which are ulcerogenic, and may cause flatulence. Increase intake of water to about 2liter a day and empirical treatment with anti H Pylori kit may be worth a try. Going by your symptomatology you are not a good candidate for surgery. Lactose intolerance, hyperthyroidism which could have gastrointestinal symptoms could be other possible cause of weight loss. Semithicone containing antacid will provide the much needed relief for gas trouble. I hope it helped Do get back to me if you have any other query. Take care Regards Dr Deepak XXXXXXX Consultant Surgeon
Above answer was peer-reviewed by : Dr. Raju A.T
Follow up: Dr. Deepak Kishore Kaltari 55 minutes later
Thanks again even if not what i want to hear.I probbaly need another gastroscopy last one in May 2012 showed moderate esophagitis and chronic gastritis in two spots (one severe one mild) but both the gastro and the surgeon told me not to stress too much about that as a lot of people scope with that and severity is often based on which radiologist analyses the samples.The biopsies at the time did not show H. Pylori.I also took the breathing test for Pylori last year and came out negative. Can you help with letting me know which foods are ulcerogenic? What is involved with this empirical test for H.Pylori (is this the breathing one i took at the lab?)Where can i get it?I would love to sort that one out again. I stopped most lactose products this summer and it helped with one cramp below the rib cage but the internal gases started about 2 years ago now.I took the blood test for thyroid gland about 2 months ago and it was fine. Mannometry done early this month showed that i have acid reflux in the esophagus after pretty well each meal and my swallowing is ok.I also have the signs of lpr in the throat since this summer.What concerns you about me not being a good candidate for surgery,too many other gastric issues? It is curious on the internet a lot of websites talk about absorption issues when ppi's are taken over the long term (over 10 years)?Also that they create an environment where bad bacterias can thrive.How do we get out of that without surgery when esophagitis is there? Look forward to your comments...
Answered by Dr. Deepak Kishore Kaltari 45 minutes later
Brief Answer: Reassessment and reevaluating of symptoms Detailed Answer: Hi, Ulcerogenic food are oily food, fried food, frozen foods. Caffeinated beverages, alcohol, carbonated drinks are all ulcerogenic. Also commonly used analgesic are Ulcerogenic. I meant empirical treatment with anti helicobacter pylori kit, it has definitely helped in many of my patients whom I put on the regimen and has helped them even though they were negative for Helicobacter pylori infection. May be the antibiotics in the kit would have treated the bacterial colonization which occurs because of long term use of PPI. Ppi may cause malabsorption because of bacterial colonization but the amount of weight loss is not significant. You mentioned having lost 20 pounds if weight, the time in which you have lost is more important. Significant weight loss is loss of more than ten percent of body weight in a period of six months. You have gastritis and complaints which may be unrelated to gerd like gas problem, which is unlikely to improve after Fundoplication. Keeping that realistic expectation in note is important before you embark on surgery. I suggest it is time for reassessment of your symptoms with your surgeon and definitely calls for repeat Gastroscopy , 24 hour ph monitoring of oesophagus along with manometry to decide for further management. I hope it helped Do get back to me if you have any other query Take care Regards Dr Deepak
Above answer was peer-reviewed by : Dr. Raju A.T
Follow up: Dr. Deepak Kishore Kaltari 10 hours later
Thank you.My BMI is still good at 23.5 but i have lost 18 pounds in 1 year without wanting it.Curiously in 2011 i went from 215 to about 198 pounds by watching my diet and i wanted to lose weight.My reward was at Christmas 2011 the acid reflux became worse and then i started having the gases and cramps also.In 2012 i started consulting with doctors and in 2013 i lost about another 20 pounds in about 1 year without really trying but on the pretty strict gerd diet and my body could not process fats very well so could not eat fats very much.So the ppi's must have something to do with that or why else would the gerd diet recommend no fats,no fried fats,etc... I understand that likely fundoplication would not resolve the gas and cramp issue but i am confident that no ppi's would mean better energy levels and with that who knows what can happen.Those pills always drove my energy levels down in last few years for sure. I agree that it is time for another gastroscopy to check the state of the system which has endured a lot in last six to seven months after i tried to get off the ppi's.I somedays think the cramp is due to ulceration but it hasn't come up on the scopes yet. Do you think an MRI where the cramp occurs may help solve that issue?The ct scan of whole abdomen did not show anything but some diverticula and slightly inflamed prostate.But that is for bigger things i understand. Would you get a fundoplication from a surgeon who has performed only 10-15 of them before because this is where you live and very few of those operations are conducted there?
Answered by Dr. Deepak Kishore Kaltari 21 minutes later
Brief Answer: Fat predisposes to reflux Detailed Answer: Greetings Fat causes increased relaxation of lower oesophageal sphincter which causes increased reflux of gastric contents into the oesophagus. All that's the rationale for avoiding fat in diet. It's quite natural and a expected sequelae of losing weight if one is on reduced or law fat diet. Ppi may slightly contribute to it by causing malabsortption due to bacterial colonization. It is just your belief and assumption that ppi are the root cause of your symptoms without any clinical basis and evidence . Fat malabsorption can be easily be tested by testing quantity of fat in stools. Getting MRI done won't provide any additional information, just adding to cost of investigation. Mri is definitely not advocated, CT scan has not picked up any abnormality. Unlikely that based on your symptoms,mri will provide any further useful information. Coincidentally diagnosed diverticula are quite a common finding in patients aged greater than 50 years especially if they consume a diet low in fiber. Diverticula may also slightly contribute to your complaints but may not be solely responsible for your complaints. They don't require further intervention apart from advising diet high in fiber. After the further work up, if your local surgeon consider surgery indicated you can go ahead with it . From the description they seem to be quite experienced. Wishing you a healthy life Take care Regards Dr Deepak
Above answer was peer-reviewed by : Dr. Shanthi.E

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