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Forum Name: Surgery Topics

Question: fundoplication wrap coming unwrapped?


 JKF - Fri Feb 17, 2006 8:38 am

I had a paraesophageal hiatal hernia and had a fundiplication wrap two and a half years ago. I was completely symptom free after this surgery. Now within the last two months the symptoms have come back. The surgery was complicated and took four hours. Is it possible this wrap could be coming unwrapped and could it come totally unwrapped. My surgeon said if it ever came fully unwrapped I would feel the worst heartburn I ever felt. I am taking prilosec otc and it isnt the worst heartburn or reflux I have ever felt at this time. Even with the prilosec I have a lot of indigestion. Do you think it will get worse?
 Dr. Tino Anthony Solomon - Tue Oct 17, 2006 2:56 pm

Hello there,

The symptoms you describe are not uncommonly reported in the short term post-operative period after the procedure. When a surgeon performs a Nissen Fundoplication operation, he or she is often faced with a difficult decision relating to the tightness of the wrap. If the wrap is too loose, then the reflux symptoms will persist after the operation, which will result in an unhappy patient. Conversely, if the wrap is too tight, symptoms of gas, bloating, and inability to belch will be major problems. Knowing what is best for the patient concerned is a combination of the art of surgery as well as the science. Experience also allows the surgeon to base his judgement on past cases as there are numerous variable factors that make exact calculations almost impossible.

Vagal nerve (the nerve controlling the movement of the stomach to propel its contents into the small intestine) damage secondary to the surgery is an unusual complication, but it can occur. Damage to the vagus nerve can impair gastric motility, however symptoms would have presented much earlier than when you describe. Unwrapping is a possibility and in some cases the wrap may need to be tightened or even redone completely. It is important to be sure that you did not have any pre-existing motility syndromes which are usually nerve mediated and thus would still cause discomforting symptoms despite the surgery. I'll assume that this was investigated for prior to the operation by your surgeon. My advice to you, if these symptoms still persist, would be to visit your surgeon and explain to him your symptoms. Alternatively visit a gastroenterologist who may arrange some scans involving ingested contrast dyes to have a better idea about the nature of your symptoms.

Dr Tino Solomon
Senior House Officer in Surgery
BSc(Hons) MB BS
 JKF - Sat Oct 21, 2006 4:44 pm

Thank you Doctor for all your information. Since I wrote that message in February in the last couple of months I have been having some horrible heartburn. I had a catscan and it showed I have a large hiatal hernia. UH OH. Back again. I have been having the worst heartburn I ever felt. My doctor switched me to prevacid in place of prilosec and it works so much better now I am not having heartburn at all. Since I have a hiatal hernia again will it necessarily turn into a paraesophageal hiatal hernia? Thank you. JKF
 Dr. Tino Anthony Solomon - Mon Oct 23, 2006 2:39 pm

Dear JFK,

Here's a quick rundown on hiatal hernia. You may already know most of this but just to recall some facts.
There are two kinds of Hiatal Hernia:
The first (95%) is the sliding hiatal hernia, where the gastro-oesophageal junction moves above the diaphragm together with some of the stomach through the opening where structures from the chest pass into the abdomen. The second kind is when a part of the stomach herniates through the hiatus but without movement of the gastro-oesophageal junction, otherwise known as a 'rolling' or paraoesophageal hernia.

The paraoesophageal type, which I gather you initially had, is usually corrected surgically even if you have no reflux symptoms (heartburn). This is because there is a small but significant risk that the stomach could become strangulated or twisted when it passes through the diaphragm. The involved section of the stomach could then die and cause rupture of the stomach wall with very serious consequences. However, a sliding hiatus hernia is altogether different as there is no great risk of a 'volvulus' or obstruction. Generally, it is first managed medically if you are suffering from chest pain or heartburn. Only if treatment fails and/or symptoms worsen is surgery considered. The difficulty here is that you have already had surgery and the procedure which normally corrects both is a Nissen fundoplication and its variants. The PPI tablets you are on are clearly not helping and this suggest that your stomach contents are being constantly pushed up your oesophagus. Losing weight is another alternative to try but I suspect that your surgical procedure may have become loosened allowing the G-O junction to move freely without being held by the muscles of the stomach, which is what a fundoplication 'wrap' aims to do. As a chronic reflux can cause changes in your oesophagus that can increase your risk of cancer in later years, combined with your intolerable symptoms, I suggest you visit the surgeon who performed the procedure with your CT scans in hand, and hear what he has to say because he is the only competent person to determine what is best in your particular case. Please keep me updated.

Dr Tino Solomon
Senior House Officer in Surgery
BSc(Hons) MB BS
 JKF - Tue Oct 24, 2006 3:28 pm

Doctor,
I will keep you posted and I am going to try to lose weight. I am not real heavy but I have a big stomach. Thank you. JKF
 JKF - Fri Dec 29, 2006 7:52 am

I had an endoscopy and it shows that the fundiplication wrap is intact. The doctor said the bad heartburn was probably caused by my bad case ifIBS. Kay
 Dr. Tino Anthony Solomon - Sun Jan 07, 2007 3:26 pm

Hello JFK,

Are you referring to inflammatory Bowel disease?

Dr Tino Solomon
Senior House Officer in Surgery
BSc(Hons) MB BS
 JKF - Sun Jan 21, 2007 6:52 pm

Yes I meant to type IBS, Inflammatory bowel disease. Sorry. JKF
 Dr. Tino Anthony Solomon - Mon Jan 22, 2007 6:02 pm

Hello again,

The medical community often uses the abbreviations IBS and IBD when referring to the following condtions:

IBS- Irritable Bowel Syndrome

IBD- Inflammatory Bowel Disease

Hope this is useful.

Kind Regards,

Dr Tino Solomon
 JKF - Wed Jan 24, 2007 9:04 am

I have irritable bowel syndrom IBS Sorry. Its confusing. JKF
 Dr. Tino Anthony Solomon - Thu Jan 25, 2007 3:36 pm

Please let us know if your symptoms settle as it is rather odd for IBS to cause heartburn. Click on the following link for more information which you may find useful.

http://en.wikipedia.org/wiki/Irritable_bowel_syndrome



Kind regards,

Dr Tino Solomon
BSc(Hons) MBBS
Senior House Officer in Surgery
 JKF - Thu Jan 25, 2007 8:07 pm

The Prevacid that I am now taking has removed the effects of heartburn I was having. Without it I would still be having the heartburn I guess. I don't know why I am having the heartburn except what my doctor told me--the IBS, I don't understand it either. He did put me on another medicine Carafate. Is that for I BS? JKF
 Dr. Tino Anthony Solomon - Wed Feb 07, 2007 3:58 pm

Hello again JFK,

Carafate is the trade name of the drug SUCRALFATE. This is used to form a protective coat over the site of a stomach or intestinal ulcer giving it time to heal well. It is sometimes given after an ulcer has healed to allow the tissue in your gut to regain its natural form without being subjected to more acid damage.

It appears from this prescription that your doctor has diagnosed an ulcer in the past or believes you have one now and is simply treating you for it. As always, please check with him as these boards do not substitute for consultation.

Kind regards,

Dr Tino Solomon
MBBS BSc(Hons)
Senior House Officer in Surgery
 Dr. Anthony Solomon - Thu Feb 08, 2007 3:21 pm

Dr Tino Solomon,

I have followed this patient's posts and your excellent responses and advice with keen interest.


Dr Anthony Solomon
 JKF - Mon Feb 12, 2007 7:54 am

Dear Doctor, He has not told me I have an ulcer but some of the pain I have had felt like an ulcer. Different than any heartburn I have felt before. Like a gnawing pain in my stomach not like burning. I am supposed to make an appointment to se my gastro doctor and will do so today. If I have an ulcer he hasnt told me so yet at least. The carafate helps the pain. Thanks Kay
 withering away - Thu May 17, 2007 12:31 am

I am a desperate daughter looking to help my mom. She had this procedure 5 years ago, and is still in severe pain, weighs now 77 pounds and has been put on dissability, and told it must be IBS or in your head.
profile of patient
w/f
56 years old
5 ft 1 in tall
current meds: atenolol, nexium (she quit taking the myralax)
pre op 130 lbs complaints were severe acid reflux and stomach pain.
First thing done was removal of gall bladder...symptoms remained.
Next procedure was upper endoscopy diagnosis was barretts oesophegeus with 3 pre cancerous lesions.
Next was the Nissen.
Since the procedure my mother has had few days of viable living. She spends hours at a time lying on the couch in pain especially after eating or drining the smallest portions, the few hours left in a day she usually spends standing in a steaming hot shower, claiming the hot water beating on her stomach gives her some yet minute relief.
We have visited every doctor under the sun, had almost every test from both ends, and every kind of xray and scan you can imagine. She has even had more ph tests, swallowed a capsule that takes pictures from one end to the other, has had all kinds of contrasts, even exploratory surgery. They can find nothing. She ends up in the emergency room every couple of months with dehydration, and is extremely malnourished. They always give her fluids and send her home. No one seems to be too concerned with her weight loss. From some of the reasearch I have done on the internet, two things ring home with her symptoms, once is the wrap is too tight, the second sounds alot like G.I.S.T. What tests should we beg her doctor to do, and how do we covince him, he needs to keep looking until he finds out what is wrong. It's not in her head, nor mine.
Please help
Terri
 withering away - Tue Jul 17, 2007 2:05 pm

Since my post I would like to update any who were concerned or even baffled. After many gastro-docs, therapists, endocrinologist.....all whom are specialist in their own design, yet fail to look out of the box because it was not part of "their specialty" after many scans, x-rays, mri's hideascan, hover scan, cat scans ultra sounds so on and so on.....my mother has been CURED!!
I had this whole list of gripes typed in here, but realized that doesnt help anyone if I bash all the medical help she received so I will leave only this note.....don't stick with one doc, even one specialist, if you are not being helped in the way you feel you should be.....Keep looking, there are docs that love to investigate things and follow all the way thru, no matter what his specialty.....and he may be the one to say it was something simple and just overlooked for years.....and .....he hands you your cure!
Terri

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