Gastroesophageal reflux disease (GERD) is a widespread condition affecting a significant portion of the adult population. While many individuals find relief through proton pump inhibitors (PPIs), a powerful class of acid-reducing medications, some experience persistent and severe GERD despite high doses of these drugs. In such cases, a surgical procedure known as Nissen fundoplication may be considered. This article explores the Nissen fundoplication procedure, its potential side effects, and the complex relationship between the surgery, weight loss, and obesity.
Understanding GERD and the Nissen Fundoplication
GERD arises from the irritation of the esophagus by stomach acid, with symptoms ranging from common heartburn to esophageal tissue damage. The underlying cause often involves an unusual relaxation of the lower esophageal sphincter (LES), a muscular valve that normally prevents stomach acid from flowing back into the esophagus. Other contributing factors include increased frequency of transient sphincter relaxation, pressure from the stomach due to a hiatal hernia, or elevated pressure within the abdomen.
The Nissen fundoplication, named after the German surgeon Dr. Nissen, aims to reinforce the LES. The procedure involves stitching closed any hernia in the diaphragmatic hiatus and wrapping the upper part of the stomach (fundus) around the junction between the esophagus and stomach. This augmentation strengthens the natural sphincter muscle, which may not be functioning correctly. Laparoscopic Nissen fundoplication is now considered the gold standard surgical approach for treatment of severe GERD.
The Link Between Obesity and GERD
Obesity is a well-established risk factor for GERD. The incidence of GERD increases with rising body mass index (BMI). Constant pressure on the stomach, caused by excess weight, can force gastric juices into the esophagus. Large meals, especially consumed at night, further stress the gastro-esophageal junction, promoting acid reflux. A dilated gastric fundus can also contribute to frequent transient lower esophageal sphincter relaxation episodes, leading to increased gastric content reflux into the esophagus.
Weight Loss After Nissen Fundoplication: What to Expect
Weight loss is a common, though not always significant, side effect after hiatal hernia or Nissen fundoplication surgery. There are several reasons why this occurs:
Read also: Impact of Nissen Fundoplication on Weight
- Dietary Modifications: Post-surgery, patients typically start with a liquid diet, gradually progressing to soft foods and eventually a normal diet. This altered eating pattern can lead to temporary weight loss.
- Reduced Stomach Size: The procedure may reduce the size of the stomach, leading to feeling satisfied with less food.
- Body's Response to Surgery: The body's natural response to surgery can also lead to a temporary loss of appetite.
A study published in Surgical Endoscopy in 2005 by Neumayer et al. demonstrated weight loss after Nissen fundoplication, showing persistent weight loss of around 9 pounds at one year after the procedure in a group of patients with an average starting BMI of 27.6.
Nissen Fundoplication and Bariatric Surgery: A Combined Approach
Given the strong relationship between GERD and obesity, a combined approach addressing both conditions may be considered. Weight loss, healthy food choices, and small meals benefit both overweight individuals and heartburn patients.
Nissen fundoplication, gastric sleeve surgery, and Roux-en-Y gastric bypass all have the gastric fundus in common. Whether the gastric fundus is wrapped, excised, or bypassed, the end result can be weight loss, decreased meal size, early satiety, lower Ghrelin levels, and decreased acid reflux. The gastric sleeve and gastric bypass procedures are great solutions for GERD and obesity.
Patients who are more than 50 pounds overweight and who suffer from multiple obesity-related comorbidities like type 2 diabetes should strongly consider weight loss surgery over Nissen fundoplication for treatment of GERD. Nissen procedure is associated with some weight loss but not enough when compared to gastric sleeve surgery or gastric bypass procedure.
Managing Weight After Hiatal Hernia Surgery
Managing hiatal hernias often begins with dietary and lifestyle changes. However, surgery may be necessary in severe cases. Weight loss after hiatal hernia surgery is one of the most common short-term side effects.
Read also: Fundoplication Diet Guidelines
Pre-Surgery Weight Loss
Doctors often recommend a plan to safely shed extra pounds to overweight hiatal hernia patients. This is because, for those who are obese, weight loss can significantly improve and even resolve hiatal hernias altogether. Without the extra pressure from fatty tissue surrounding the stomach, the digestive system can rest naturally in place and function more efficiently.
Post-Surgery Weight Loss
The body’s response to surgery, an expected loss of appetite, and dietary restrictions can all lead to weight loss after hiatal hernia surgery. Dropping a few pounds over the course of a few weeks is normal for most patients. Most people can expect to gain this back within the next few months as more normal eating habits resume.
Side Effects of Nissen Fundoplication
In addition to potential weight loss, other side effects can occur after Nissen fundoplication:
- Difficulty Swallowing: This is a common short-term side effect that usually improves with healing.
- Discomfort at the Surgical Site: Pain and discomfort are expected in the initial recovery period.
- Abdominal Bloating: Bloating can occur due to changes in digestive function.
- Nausea: Nausea is another potential side effect, which can be managed with medication.
- Inability to Vomit: The same procedure that keeps stomach acid out of your esophagus can keep you from throwing up. Your stomach dumps whatever’s upsetting it into your intestines.
Long-Term Considerations and Potential Complications
While Nissen fundoplication is generally considered a safe and effective procedure, some long-term side effects and potential complications exist:
- Recurrence of GERD Symptoms: The most significant risk is the return of GERD symptoms, requiring further intervention.
- Gas Bloat Syndrome: Difficulty in belching or vomiting can lead to increased bloating and discomfort.
- Dysphagia: Difficulty swallowing can persist in some cases.
- Paraesophageal Hernia: In rare cases, the fundoplication can migrate into the chest.
Factors Affecting Success
Several factors can influence the success of Nissen fundoplication, including:
Read also: Nissen Fundoplication vs. Toupet for Acid Reflux
- Surgeon's Experience: The surgeon's skill and experience play a crucial role in the outcome.
- Patient Selection: Careful patient selection is essential, considering factors like the severity of GERD, overall health, and BMI.
- Preoperative Evaluation: Thorough preoperative evaluation, including endoscopy, manometry, and pH monitoring, helps identify the underlying cause of GERD and guide surgical planning.
Nissen Fundoplication in Obese Patients: A Complex Issue
The effectiveness of Nissen fundoplication in obese patients has been a subject of debate. Some studies suggest a higher long-term failure rate in obese patients (BMI > 30). Hiatal hernia repair and complete circumferential distal esophageal dissection are challenging in obese patients. It is almost impossible to properly release the distal esophagus in the setting of a large liver and thick abdominal wall.
When surgical treatment of GERD is indicated in a morbidly obese patient, laparoscopic Roux-en-Y gastric bypass surgery, rather than fundoplication should be strongly considered. Gastric bypass surgery not only better address the mechanisms that lead to GERD in morbidly obese patients with high efficacy and durability, but it also addresses the obesity-related comorbidities by achieving significant and sustained weight loss.
Recovery and Post-Operative Care
Following Nissen fundoplication, careful adherence to post-operative instructions is crucial for a smooth recovery. These instructions typically include:
- Dietary Progression: Following a prescribed diet, starting with clear liquids and gradually advancing to solid foods.
- Medication Management: Taking prescribed pain medication and anti-nausea medication as needed.
- Activity Restrictions: Avoiding heavy lifting and strenuous activities for a specified period.
- Incision Care: Keeping incision sites clean and dry to prevent infection.