I have heard that the Nissen procedure doesn't work very well and has bad side effects.
Are patients able to belch or vomit after a laparoscopic fundoplication?
What is recovery like?
At what point should I consider either surgery or an endoluminal procedure?
I was told I have a hiatal hernia. Doesn't that need to be fixed?
I'm worried about cancer developing because I have reflux. What should I do?
I have recurrent reflux after my first procedure. Can surgery be redone?

I have heard that the Nissen procedure doesn't work very well and has bad side effects.
The Nissen procedure has been performed since the 1950s and has gone through several modifications during that time to help minimize side effects and improve success. Randomized studies show that surgical therapy, when offered to patients who are well controlled by medical therapy, does better at controlling reflux symptoms as well as controlling acid exposure in the esophagus (Lundell).The American College of Gastroenterology states that surgery is an acceptable alternative to medical therapy in patients with chronic GERD (Am J Gastroenterol, June 1999 94(6):1434-1442.) The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) states "Two controlled trials which compared medical and surgical therapy of GERD favored surgical therapy. In the most recent prospective randomized comparison, surgical treatment was significantly more effective than medical therapy (ranitidine and metoclopromide) in improving symptoms and endoscopic signs of esophagitis for periods of up to two years. Other longitudinal studies report good to excellent long term results in 80-93% of surgically treated patients".
Improvements in surgical technique, including the use of an acellular collagen matrix to reinforce the diaphragm hernia repair, have increased the durability of the laparoscopic Nissen procedure to over 95% in the first year after surgery. (Our follow-up is still short but we anticipate seeing significant long-term improvements as well.)
The incidence of side effects such as bloating, diarrhea, and difficulty swallowing are somewhat greater in patients treated with antireflux surgery compared to those treated with medical therapy. In our experience, uncomfortable bloating occurs in less than 5% of patients, and we have had to revise the surgery in fewer than 0.5% of patients because of bloating issues. Problems with swallowing requiring intervention (dilation or revision), once postoperative swelling has subsided, occurs in less than 2% of our patients. Increased flatulence is present in 30% of patients after antireflux surgery. It is because of these surgical side effects that (1) we generally reserve surgical therapy for patients whose reflux symptoms are inadequately controlled by proper medical therapy, and (2) we are excited to offer the Esophyx procedure in appropriate patients.-Top of Page -

Are patients able to belch or vomit after antireflux procedures?
The majority of patients are able to belch after laparoscopic antireflux surgery including the laparoscopic Nissen. Studies measuring the ability to belch indicate a decreased frequency after a laparoscopic Nissen. It is thought that this decreased frequency may be the reason that some patients note uncomfortable abdominal bloating after the procedure..-Top of Page -

What is recovery like after the Esophyx or a laparoscopic Nissen?
After the Esophyx procedure there are no limitations on physical activity, but diet is restricted for the first 6 weeks to liquid or very soft foods, to prevent tearing in the area of the fundoplication. After the laparoscopic Nissen, physical activity is restricted from 4-6 weeks to allow the hiatal hernia repair to heal. Diet restriction is simlar to that for the Esophyx procedure, although it may take longer for the swelling to resolve and to attain a solid diet.-Top of Page -

At what point should I consider either surgery or an endoluminal procedure?
In general, surgery should be considered when medical therapy no longer provides adequate control of reflux symptoms. Further evaluation to determine that the persistent symptoms are indeed due to reflux is often indicated prior to making a recommendation on whether surgery is appropriate, as we occasionally find that these persistent reflux symptoms are not due to GERD but to some other cause (e.g. gallbladder problems). We will then help the patient assess the potential benefits and risks of surgery to help him or her decide on the best course of action.
The Esophyx procedure has fewer risks and side effects than a laparoscopic Nissen procedure, and so the Esophyx can be considered as an alternative to successful medical therapy in those patients who like to avoid medication if possible. The limitation of the Esophyx procedure is that its long-term durability is not known at this point, and success at controlling reflux is likely to be less than that of the Nissen procedure. However having the Esophyx procedure once does not preclude repeating it, or having a laparoscopic fundoplication.-Top of Page -

I was told I have a hiatal hernia. Doesn't that need to be fixed?
Many patients have been told that they have a hiatal hernia and what is really meant is that they have GERD, gastroesophageal reflux disease. Unlike groin hernias, most hiatal hernias do not cause pain, but instead aggravate reflux. In cases where surgery is indicated for severe GERD, the hiatal hernia is repaired during the surgery. The Esophyx procedure, which is limited to patients with a small hiatal hernia, stabilizes the hiatal hernia during deployment of the plicating devices. -Top of Page -

I'm worried about cancer developing because I have reflux. What should I do?
Patients with chronic gastroesophageal reflux are at higher risk for developing esophageal cancer, and appropriate screening should be performed. If you have had GERD symptoms for greater than 10 years, or you develop problems with swallowing, then you should be evaluated to see whether screening procedures such as an upper endoscopy (EGD) and/or a barium swallow are indicated. We recommend a consultation with a Gastroenterologist regarding these issues.
Patient's with a change in their esophagus called Barrett's esophagus are at even higher risk of developing esophageal cancer, and should be in an appropriate screening program devised by their Gastroenterologist.
At this point there is no evidence that antireflux surgery prevents the development of cancer in patients with Barrett's esophagus, although it may reduce the risk of Barrett's progressing to cancer. For this reason patients with Barrett's who have had antireflux surgery should continue to be seen and screened by their Gastroenterologist. Having a Nissen procedure does not preclude endoscopic screening. -Top of Page -

I have recurrent reflux after my first procedure. Can surgery be redone?
Patients who have had good control of their reflux after a Nissen procedure, and then develop recurrent reflux, should first be treated medically. If medical treatment fails to control symptoms (which occurs about 1/2 of the time), and testing demonstrates recurrent reflux and a mechanical disruption of the initial surgery, then reoperation is successful at improving reflux over 80% of the time. Reoperation can be accomplished laparoscopically much of the time if the first operation was done laparoscopically. We have performed over 150 reoperative Nissen fundoplications, the majority laparoscopically. -Top of Page -