Surgery For Heartburn: Nissen Fundoplication
When do we operate for heartburn?
Heartburn is caused by acid and intestinal fluid backing up from the stomach into the esophagus. The esophagus is the tube that carries food from the mouth down to the stomach. Although many people suffer from heartburn and regurgitation, surgery is rarely done for this problem. Often, non-surgical measures can solve this problem. These would include avoiding coffee, chocolate, alcohol, orange juice, and aspirin; elevating the head of the bed; and taking antacids and acid suppressing medications. Surgery would only be appropriate if there was evidence of continuing damage to the esophagus in spite of these measures, and if tests indicated that the main problem was that the opening between the stomach and esophagus did not close tightly after swallowing. There are also situations where surgery is performed even though medications are effective in controlling the symptoms so a patient doesn't have to permanently require medications.
About the operation
There are two ways to perform this operation: "open" and "laparoscopic". These operations accomplish exactly the same thing, but are performed with different types of incisions.
The laparoscopic approach uses five small incisions. The first of these incisions goes under the belly button. A laparoscope is inserted through this incision which allows us to see into the abdomen. After this four other incisions are made through which several long, thin instruments are placed into the belly.
Once all the incisions have been made and the instruments inserted, the next portion of the procedure consists of repairing the opening in the diaphragm. The diaphragm is the thin layer of muscle between the chest and the belly. The opening through which the esophagus goes is abnormally large in patients with heartburn. Stitches are placed to bring this opening back down to normal size.
The upper stomach is then wrapped around the lower esophagus, and sewn in place. This is called a "wrap" or Nissen Fundoplication. It creates a valve at the bottom of the esophagus which prevents acid from backing up into the esophagus. The operation usually takes anywhere from one to two hours.
The open approach begins with a vertical (up and down) incision between the belly button and the bottom of the breast bone. The actual operation is the same as the laparoscopic approach. In general, we try to perform the procedure laparoscopically if at all possible, but if the operation can not be done properly or safely through the scope, it is converted to an open procedure.
After the operation
This procedure is often done as an outpatient, or with only a one day hospital stay. How long a patient needs to stay in the hospital depends on how well the patient is doing with pain control and swallowing. Because we are making the opening between the esophagus and stomach smaller, swallowing can be difficult for the first few weeks.
If the procedure was done laparoscopically we usually recommend that patients plan to take about a week off work to recover. However, there is no actual restriction on activity. If the open procedure is done, it is important to avoid any lifting after the operation for at least the first four to six weeks.
Most patients find that their heartburn is gone immediately after the operation, and doesn't return. We usually ask you to stop taking your stomach medications after surgery to see how you will do. Some patients do need some medication even if the surgery is successful, but most do not need any medications at all.
We have been performing this procedure at Evergreen Surgical since 1995 with excellent results in over 95% of our patients. Feel free to call our office directly if you need more information about this, or would like to schedule an appointment.
Other articles on Heartburn:
"Living with Heartburn, by Dr Immerman, published in Healthy Viewpoints."