Possible unsuccessful Fundplication -- help!
mrmonster
big hiatal hernia. Previous to this, I had been taking Aciphex and
was sleeping at a serious incline. A manometry test showed a very weak
esophagal sphincter. This precipitated a meeting with a surgeon and
then the decision to have the surgery. I basically didn't want to
take meds and sleep at an angle the rest of my life.
The surgery took place in NY and was done by lap surgeon with about
130 fundos under his belt. It went "textbook," according to the
surgeon.
Well, the surgery has definitely improved my heartburn situation, but
I'm afraid to report that I've gone back on meds, and I'm thinking of
putting the wedge back under my mattress. Without the meds, I
experience a persistent, but not so severe burn in my sternum, and
when I wake up in the morning, my chest area feels raw (though I'm not
woken up in the middle of the night by heartburn as I had been before
the surgery). Popping a Zantec gets rid of the burn, at least for a
while. A few days ago, I went back on aciphex, and that has helped
also, except for when I woke up this morning and felt it in the chest
again. It's been bothering me all day. The funny thing is that it's
not the outright strong heartburn I used to feel, but a milder
version. It reminds me of the times I'd try to get off PPIs. The first
day would be ok, then I would feel this kind of pre-heartburn light
burn, before getting the full on heartburn. Anyway, my conclusion is
that the surgery was not completely effective -- not in the least. I
met my surgeon 2 weeks after the fundo for a followup, but he wasn't
concernced, said I was still healing, and that the discomfort I was
feeling would be gone in a month. Well, I'm seeing him again next
week, and I want to handle this right. What kinds of questions should
I be asking him? I'm sure he's not going to make a judgement about the
situation without at least a PH test, but I want to make it clear to
him that I'm not convinced anymore that I'm simply healing
Needless to say, I'm disappointed, and would love to hear any advice
that any of you might have.
thx
Howard McCollister
mrmonster <dickbro...@yahoo.com> wrote:
No, you're not still healing. Your heartburn should be gone. In a
situation like yours, an EGD is necessary to look at the wrap, determine
if it has "slipped", pulled up through the diaphragm (you said you had a
large hiatus hernia) or simply loosened. At the same time as that EGD,
I'd place a Bravo pH transmitter capsule. Then, you would know whether
or not you are refluxing, and if so, why.
Sometimes, if there is a large hiatus hernia, there may be associated
shortening of the esophagus from scarring. An experienced surgeon would
recognize this and either do a lot more mobilization of the upper
esophagus or lengthen it with a Collis-type wedge fundoplasty. the
penalty for not recognizing it is that the esophageal shortening, over
the next several weeks, begins to pull the esophagus upward through the
wrap, sort of like pulling a hot dog out of a bun. The other possibility
is that it can pull the whole wrap through the opening in the diaphragm
(transiatal herniation). In either case, the fundoplication becomes less
effective.
There is also the possibility that the fundoplication was too loose, and
has loosened even more. Fundoplications can and do loosen over time, but
usually a lot more time than a couple of months.
HMc
Pete
Sorry to hear about your predicament. Howard (our resident GERD and lap
Nissen expert) has responded to your question. May I ask if you had (or
still have) any difficulty swallowing or belching after the surgery, and for
how long did it last (or do you still have it). Thanks...Pete
mrmonster
>
> Sorry to hear about your predicament. Howard (our resident GERD and lap
> Nissen expert) has responded to your question. May I ask if you had (or
> still have) any difficulty swallowing or belching after the surgery, and for
>
> - Show quoted text -
Thanks to Howard and Pete for your quick responses. Pete: if by
difficulty swallowing, you mean did food occasionally have trouble
passing through the esophagus, yes for the first few weeks after I got
off liquids, sometimes a piece of food would get stuck on its way
down, and I would ease back to softer things. But now that's gone. I
can eat pretty much anything. As for belching -- not exactly. My
stomach would try to -- it would convulse, which was a very odd
feeling, but it wouldn't produce anything but occasionally the tiniest
burp, but not a traditional belch.
Howard: So basically, I'm screwed here, right? I mean, I need another
surgery if I want to fix this?
Howard McCollister
mrmonster <dickbro...@yahoo.com> wrote:
Too early to tell - need EGD and pH testing to know. The poor belching
and difficulty swallowing are a typical course for a successful
fundoplication.
I've seen this happen before at the 6 week-or-so mark, unrelated to
failure. It can be esophageal reflux, or a spasm issue. Don't start
planning your next operation yet. I understand your anxiety and
pessimism, but really, we need more info.
HMc
Pete
I wish you the best of luck. Please keep us informed...Pete
mrmonster
and I guess we'll take it from there. I'll keep you posted.
Interesting side note: Howard mentioned spasms. When I first got the
manometry test, the GI mentioned seeing spasms in -- if I recall this
correctly -- the chest area, and he wondered if that was the cause of
some of my problems. The observation, though, never made it into his
report on the test. I'm going to bring it up with the surgeon.
betai...@yahoo.com
I'll add my comments. The wedges and blocks under the head
of the bed are not enough to provide adequate incline. I use 18
inches of extra height at the head of my bed, I find it very helpful.
And in combination of an acid supplement for dyspepsia, I've
been symptom free for three years. I had a fundo that
went somewhat leaky with time. After a year I was back
in the H-2 acid reducer and then by three years I was on
Aciphex, then a break, then Domer/Prilosec. The
adverse effects from the PPI meds got to be too much.
So I tried alternative medicine.........amazing........
the dyspepsia is gone provided I take the digestive
supplement and I still sleep on the inclined bed with
a foam mattress. Inner spring mattresses don't
seem to work well when inclined....back pain!!!
I know Howard has different views and he is very
good with his skill set but I'll suggest there are other
options.
Howard McCollister
betai...@yahoo.com wrote:
I'm in favor of anything that works for control of an individual
patient's GERD symptoms, as long as they realize that symptom
suppression for that doesn't address the underlying mechanism of GERD.
It doesn't cure the problem, it only manages the symptoms. That's true
whether the treatement is a PPI, ginger root, or betaine HCl.
Symptom-free is not the same thing as GERD-free, and EGD surveillance is
still indicated every 1-3 years.
HMc
betai...@yahoo.com
> In article <1184083924.674039.209...@57g2000hsv.googlegroups.com>,
I'll agree with that overall. I know that NSAIDs, aspirin, and
certain
herbals with NSAID like drug actions can start to cause soreness.
I am of the opinion that sleeping on an extreme incline does a bit
more because the action reduces total reflux exposure. And I agree
there is no complete cure but rather there are treatments and regimens
of various levels of effectiveness. I even agree with you on the
point about surveillance.
I've suggested to others that posting this forum for your point of
view would be useful, Howard.
I after all only know what helped me; whereas, you have a deep range
of
experience with others plus an on topic education.
Live long and prosper
mrmonster
not belching indicates that the wrap is probably in good shape, and
seems in opposition to the fact that I'm still showing symptoms
(albeit much less pronounced than before the surgery). The symptoms do
seem to be reflux related since they're being controlled by meds
(PPIs, H2 blockers, and regular antacids-- they all help). He still
wants to give it two more months before ordering tests: his says it
takes at least 90 days --- and I'm paraphrasing here, so it's not
exact -- for the new valve structure to be completely formed; the
organs still need to settle and find their places. If I'm still
experiencing symptom in 2 months he wants to do a barium study, and if
that's clear, a Bravo pH test. He didn't mention a shortening of the
esophagus situation or a transiatal herniation that Howard brought up,
and I thought I'd hold off on asking about that for the time being. He
did mention the possibility that my esophagus might be producing some
acid on its own. Something-plasty he called it, I think. Some stomach
cells in the esophagus producing acid, but not a Barrett's situation
(my last EGD in November was clear). If that's the case, then I'll
have to go back permanently to PPIs.
I'm actually OK with waiting for another 2 months; I need a break from
doctors and tests. Anyway, does what the surgeon said make sense?
betaine_hcl: I've been reading for a long time your comments about
wedges and such over at the Yahoo group, and it inspired me last year
to get a serious sized wedge to put under my mattress. I actually
ordered over the web a custom cut piece of foam -- huge, actually --
that significantly raised my torso. It helped tremendously. It didn't
get me off PPIs, but I no longer needed to supplement the PPIs with
tums or Zantecs.
Howard McCollister
mrmonster <dickbro...@yahoo.com> wrote:
> So I saw the surgeon today, and this is what he had to say: That I'm
> not belching indicates that the wrap is probably in good shape, and
> seems in opposition to the fact that I'm still showing symptoms
> (albeit much less pronounced than before the surgery). The symptoms do
> seem to be reflux related since they're being controlled by meds
> (PPIs, H2 blockers, and regular antacids-- they all help). He still
> wants to give it two more months before ordering tests: his says it
> takes at least 90 days --- and I'm paraphrasing here, so it's not
> exact -- for the new valve structure to be completely formed; the
> organs still need to settle and find their places. If I'm still
> experiencing symptom in 2 months he wants to do a barium study, and if
> that's clear, a Bravo pH test. He didn't mention a shortening of the
> esophagus situation or a transiatal herniation that Howard brought up,
> and I thought I'd hold off on asking about that for the time being. He
> did mention the possibility that my esophagus might be producing some
> acid on its own. Something-plasty he called it, I think. Some stomach
> cells in the esophagus producing acid, but not a Barrett's situation
> (my last EGD in November was clear). If that's the case, then I'll
> have to go back permanently to PPIs.
>
> I'm actually OK with waiting for another 2 months; I need a break from
> doctors and tests. Anyway, does what the surgeon said make sense?
While it is indeed possible that the wrap is fine, and that your
symptoms are due to local trauma, dysphagia, motility abnormalities, my
bullshit alarm just went off a little. Not full-on...just a couple of
chirps.
I agree there is no harm in waiting, if you can hack the symptoms. 90
days for the "valve structure to form" is...um...well, I disagree. The
suggested "acid producing cells in the esophagus" concept is worrisome -
*that* is baloney. The esophagus has no acid secreting cells. If that's
what's happening, then he created the fundoplication too low and there
is actual stomach (with its acid-secreting cells) above the wrap . The
fundoplication *has* to be above the LES in order to function. If it is
created too low (on the stomach instead of esophagus), then there are
problems, and those problems are consistent with the symptoms you
describe. And, the main reason for the wrap being too low is shortened
esophagus - either it was created there (fairly easy to do if the
surgeon is unwary), or the shortening of the esophagus pulled it there
in the post-op period (pulling the "hot dog out of the bun"). That
represents what's called a "slipped Nissen" and thus we come full circle
back to my original post in this thread (I think). I don't mean to sound
critical of your surgeon...but a significant part of my work-week
involves referrals for fixing Nissens that have gone bad. There are a
lot of bad Nissens out there.
My first thought at this point would be to modify your diet to smaller
meals, eat more swallow-able foods (avoid food for the time being that
is more solid than, say, scrambled eggs). Eat slowly, chew thoroughly,
avoid meats like chicken, ham, steak. Avoid bread. Some of your symptoms
may also be due to bloating of the stomach from air-swallowing. Stop
doing that. And no carbonated beverages, no drinking straws, no chewing
gum. Sip, don't gulp.
HMc
mrmonster
that the surgeon might be talking baloney possibly to avoid admitting
a failure of some kind. That would suck. I really like this guy, too.
I'm going to try to get a copy of his report of today's appointment.
In the meantime, I'll retreat to the diet you recommended (wah!); it
is true that I have never been the best chewer. In fact, people have
always said I eat too fast. I'm trying to be better about that.
Really.
And I'll report back in a couple of months.
Howard McCollister
mrmonster <dickbro...@yahoo.com> wrote:
Let me backtrack a little. I don't mean to suggest that he's trying to
put one over on you or misleading you in any way - I just disagree with
the concept of acid producing cells in the esophagus. I know how easy it
is to misidentify the LES and how hard it is to accurately judge the
amount of intraabdominal esophagus around which to put the wrap. A
Nissen fundoplication is technically pretty easy for an experienced
laparoscopic foregut surgeon, but there are some possible pitfalls in
the technique that have clearly demonstrated that it's not as easy as we
all thought it was 6 or 7 years ago.
HMc