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Old 09-16-2009, 01:40 PM   #1
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Nissen for LPR? Is it really necessary?

Okay so I've been struggling with LPR for almost a year. Started with feeling a lump in my throat and excessive mucous and throat clearing. I've had an endoscopy, 24 ph, and manometry. My 24 hour pH and endoscopy were completely normal. My manometry however showed that my esophagus was hypotensive and did not contract like it was supposed to when I swallowed. My GI doc did not have an answer for this.

My ENT has looked at my throat/vocal cords 3 separate times. Once when he first diagnosed me. Once 4 months after being on prilosec twice daily. Then today after being on nexium for 4 months twice daily. My symptoms are better but apparently my vocal cords are still red and inflamed!!

He said for me to continue my BID Nexium but that he wanted me to go see a surgeon to evaluate me for a Nissen Fundoplication. He said that continued irritation to the throat can lead to throat cancer. He says I need to stop this while I can.

I'm only 24! I'm too young for surgery! I'm a registered nurse and I've seen too many surgeries go wrong. I'm going to go talk to the surgeon but I'm going to bargain with him. Give me one more year to see if my throat can heal. I'll do anything not to have surgery. I'll live off rice and bread if I have to.

I seriously have a surgery phobia... I mean do you think my ENT is rushing things or what?

 
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Old 09-16-2009, 06:08 PM   #2
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Re: Nissen for LPR? Is it really necessary?

Quote:
Then today after being on nexium for 4 months twice daily. My symptoms are better but apparently my vocal cords are still red and inflamed!!

He said for me to continue my BID Nexium but that he wanted me to go see a surgeon to evaluate me for a Nissen Fundoplication. He said that continued irritation to the throat can lead to throat cancer. He says I need to stop this while I can.
That's an exceptionally aggressive approach to GERD. It often takes several months of medication AND lifestyle changes to get GERD under control so being on Nexium for 4 months and Prilosec for 4 months is a fairly short period of treatment to even begin considering the Nissen procedure.

While he is technically correct that continued irritation can lead to throat cancer, the percentage of people who progress from GERD to cancer is VERY small, and cancer is typically a much bigger concern in patients with Barrett's esophagus than in those with "run of the mill" GERD. Barrett's is a complication of GERD so the progression is typically GERD > Barrett's Esophagus > Esophageal cancer.

While the numbers aren't exact, about 15% of people with GERD develop Barrett's (and they are most likely the ones whose GERD is untreated or poorly managed), and only .5% of people with Barrett's develop esophageal cancer. That means that 1 in 1,333 people with GERD can be expected to develop Barrett's esophagus (these percentages come from 2 different studies and aren't definitive in terms of the percentages or the projections, I just thought it would be helpful to have some context on the odds).

On top of that, the Nissen Fundoplication procedure is a complicated, invasive procedure that is truly a last resort.

I think the best thing would be for you to find a gastroenterologist who can give you some better answers, work with you to treat your GERD (including making lifestyle changes), and monitor your condition over time. Sometimes you have to try multiple medications to find one that works but, it definitely seems like it's too soon to pursue surgery unless there is some other complicating factor.

 
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Old 09-17-2009, 06:57 AM   #3
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Re: Nissen for LPR? Is it really necessary?

Thank you for your response. I've decided that I am going to see a 2nd ENT to get his opinion. Then revisit the subject with my GI doctor. Then I will go from there. Like you said surgery is permanent and a last resort type of thing.

I feel guilty getting a second opinion because my ENT has been so good to me and has taken all of my concerns seriously. Being a nurse and constantly seeing people so sick makes me feel like my little problem is so silly.


Does anyone think I should just go talk to the surgeon to get his opinion? Or do you think the surgeon will push surgery just b/c that is how he makes his money?

 
Old 09-17-2009, 07:43 AM   #4
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Re: Nissen for LPR? Is it really necessary?

Quote:
I've decided that I am going to see a 2nd ENT to get his opinion. Then revisit the subject with my GI doctor.
GERD is primarily a gastrointestinal problem so I would recommend that you start with your GI doctor, not a second opinion from another ENT.

 
Old 09-19-2009, 03:30 PM   #5
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Re: Nissen for LPR? Is it really necessary?

Hi TigerGalLE,

This message is a bit long, but I wanted to share my experiences.

I'd say that for most people the Nissen Fundiplication really isn't necessary. That said, I'm one of those people who chose to have the surgery. It will be a year come October 2.

I worked in conjunction with my GI doc, Pulmonologist and ENT. (My reflux was affecting my breathing in addition to causing a chronic cough.)

I spent quite a while trying different things to get the reflux under control before I ever even contemplated surgery. Diet and lifestyle changes are the first thing you need to address. It sounds like maybe you have already made changes to your diet, but if you havent, that is a first place to start. Next is raising your bed by 6 inches. Sleeping on an incline lets gravity help you a bit. It certainly won't make the symptoms go away, but it can help a bit. Also, losing weight if you are overweight and not wearing tight clothing around your waist helps.

With regards to the medications, everyone is different in regards to which ones help them. I was able to find one that I took twice/day that helped me for several years. Then it just stopped working. My reflux is "silent" and my reflux symptoms are the same as my asthma symptoms so I didn't realize how bad the reflux had gotten. It was my Pulmonologist who told me I needed to go back to see my GI doc. In working with my GI doc, I methodically tried each PPI on the market. It took a long time because I stayed on each one a minimum of a month before trying the next one. This allowed me to see if the medication was having any affect. I also supplemented with Gaviscon, others supplement Zantac. For me, even though my GI doc said it was the best, Nexium was the worst medication ever. Even 15 months later, I'm still dealing with the side-effects of the Nexium. Most people eventually hit on one of the PPI's that works best for them though. I would think that you have more options out there than just having tried the Prilosec (which most people with LPR don't have much success with anyway) and Nexium.

My Endoscopy was normal, but my 24 hr pH and Manometry showed that my reflux was severe and my LES was functioning poorly and had gotten worse as well over the last couple years since my first test. I also had a Modified Barium Swallow and Esophagram that showed the acid coming up and irritating my lungs and throat.

Did your Manometry show if you had any problems with your Lower Esophageal Sphincter?

The Nissen Fundoplication involves wrapping your stomach around your Esophagus. The result is that every time your stomach contracts, it is contracting around your Esophagus. This keeps the acid (and vomit) from coming up into your Esophagus. Basically the Nissen is having the stomach perform the function of your LES. If your LES is functioning well enough, I'd certainly ask more questions of your GI doc, ENT and Surgeon before deciding to go that route.

If you do decide to go the surgical route, make sure your Surgeon is very experienced in performing this procedure. It makes a big difference in the success rate for you.

I finally decided upon the surgery after having tried long-term diet and lifestyle changes, all of the PPI's on the market (and some holistic things too), and having various tests confirm that my reflux continued to be severe despite treatments. My reflux not only caused me to have a chronic cough, but it affected my asthma to the point that I couldn't get it under control with medications and I needed emergency treatment. To me being able to breathe was worth the risk of the surgery. The surgery was successful in that regards, but I still remain on the PPI's long-term.

Side effects of the surgery you should consider:
-Gas Bloat Syndrome: gas normal comes up through your Esophagus throughout a normal day. With the surgery, it isn't able to come up and sometimes sits in your belly causing uncomfortable bloating.
-Chewing food: you will need to chew food well before swallowing. Be expecially careful with bread and meat. The consequence of swallowing something too large is that it can get stuck above the wrap and take a long time to go down. This can be very uncomfortable. I've had it happen a few times. Angel Food Cake was the worst.
-Vomiting: most people with the surgery can no longer vomit. Your stomach is keeping itself from allowing it. It is a wierd feeling having the vomit being pushed up and down by your stomach. I didn't worry about this pre-surgery because I rarely ever had a need to vomit. Unfortunately do to the surgery and other digestive issues, the need hits me and I end up heaving with nothing being able to come up.
-Weight: you will need to be careful not to ever exceed the weight you were at before you had the surgery. Doing so can result in stress on your stitches and could potentally cause them to fail and the procedure to become undone.
-Incinsions: My procedure was done Laproscopically. I have 6 small incisions that were closed with steri-strips. Five of the scars are visible across my abdomen, the other was in my belly button.

You need to make sure the benefits of the surgery outweight the side-effects. For me they did.

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Old 09-20-2009, 07:45 AM   #6
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Re: Nissen for LPR? Is it really necessary?

Wow thank you for that excellent post. So much good information. To answer your question my LES was functioning normal.It was my esophagus that does not contract fully to move food into my stomach. This leads to food and acid staying in my esophagus for too long and refluxing into my throat. This leads me to believe that I wouldn't be a candidate for surgery anyway.

I have actually canceled my appointment with the surgeon and I am in the process of getting a referral to see another ENT. I know GCSMITH that you recommended to see the GI doctor again which I may do. But, since me symptoms are involving my vocal cords and larynx I want another ENT to scope me and look. I also want to know how at risk I am for cancer in his opinion. My current ENT has me pretty worried. My symptoms are now less frequent (chronic sore throat, mucous, lump in throat). The day I saw my ENT I was having a good day with no symptoms but there was still redness and swelling in my throat.

I'll admit I need to be more strict with my diet. I love coffee in the morning and I have about 3 cups a week. I have cut down tremendously. I also still drink soda, mainly bc water seems to make my reflux worse. And juice is out of the question, I haven't had juice in a year. My weakness is tomato based foods. It is hard for me to want to avoid them when I don't have heartburn. I just have long term effects from the foods I choose.

Well thanks again for all the good information. It is nice to know I'm not alone.

 
Old 09-24-2009, 02:57 PM   #7
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Re: Nissen for LPR? Is it really necessary?

I just had Nissen Fundoplication on 9/21/09. Afterreading post I was expecting lots of pain after surgery. Why there really was much. Yes the incisions hurt a little but I was on a morphine pump on a 1-10 scale the worse it got was maybe a 4. I am now home after spending 3 days in the hospital and just starting a very soft diet. I had to really take my time swallowing and can feel it sort of plop into my stomach. This will all get better. For the very first time in 6 years I was able to lie down on a bed and sleep. I have been trying to sleep sitting up in a chair for almost 8 years. I have had 2 vocal cord surgeries in the last year because of the alkalyn coming up on to my vocal cords and eroiding them. This pricedure is an absolute heaven sent. Yes it's early yet but with only 4 days after the surgery I am feeling well.

My stomach was different, it produces no acid. For 5 years the local gastro doc treated me for acid reflux and I was totally over meds. I got the second opinion at the university of Penn. and my stomach produces none. I have alkalyn reflux which is just as bad and maybe worse. During the surgery they also fixed a hugh Hiatal Hernia. What a blessing!!!


ED

 
Old 09-24-2009, 06:48 PM   #8
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Re: Nissen for LPR? Is it really necessary?

eds,
I agree with you on the surgery being a blessing. From the moment I woke up, my breathing was better and my coughing was gone.

I was only in the hospital for a total of 23 hours.

Be careful with how fast you add solid food back in to your diet. My surgeon had me take the slow route and it seems that I've had fewer problems during recovery than many do. I was on a liquid only (no lumps of any kind) diet for 2 weeks. I then went to soft foods. When I added solid foods, I avoided breads and meat. It was a couple months before I added them. The bread and meat don't break down when you chew. It is really uncomfortable to catch food above the wrap. It does eventually go down.

Congratulations on how well things have gone and good luck as you recouperate.

 
Old 09-25-2009, 06:32 PM   #9
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Re: Nissen for LPR? Is it really necessary?

Thanks so much for the reply. Today was the first day I tried a little creamy soup and yogert. It seems to almost feel like I have to breath a couple seconds and relax for them to go down. I almost feel a plop. A little uncomfortable but I am hoping it's just temp. I completely stopped any pain meds and it's only been since the 21th. The center of my chest does feel tight at the breast bone area but it's really early. My stomach definitely is swollen up. I feel the same as you I will take my time with the liquids and very soft diet.

I did ask my surgeon an important question before the surgery. I said Doc, do you think I'll be able to eat a Big Mac. hee hee They all laughed and he replied , "Yes two of them in do time."



ED

 
Old 10-02-2009, 09:18 AM   #10
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Re: Nissen for LPR? Is it really necessary?

So I went today for my 2nd opinion with a new ENT. He told me I had a better chance to win the lottery than to get throat cancer from my reflux. He said as long as I'm not a smoker I am not at risk. He also looked at my vocal cords again and said they looked healthy. He told me the surgery would not help me due to the fact that my problem is related to my esophageal dysmotility. He said to stay on my Nexium BID and to have an EGD every 4-5 years to make sure my esophagus stays healthy. He said esophageal cancer is more of a concern for people with reflux.

I'm so relieved to finally get some good news. I'm not sure why my other ENT was so sure I would end up with throat cancer. Hopefully this new guy is correct with his thinking. I wasn't going to have surgery anyway so at least this takes some weight off of my shoulders!

 
Old 10-03-2009, 02:05 PM   #11
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Re: Nissen for LPR? Is it really necessary?

You must have normal esophageal motility for fundoplication surgery. It is a requirement. ANy surgeon doing the surgeon with esophageal dysmotility shouldn't be practicing. You would never be able to swallow. If you sreach the web for reflux and esophageal cancer you will see there is a relationship between the two. If you continue with your PPI inhibitors like your ent suggests you will control it an should be fine. An ENT can not see into you esophagus nor does he has anything to do with it, you must go to a gastrologest for that and get full scoping to be 100% sure. Anything less and you are taking a chance.

It has been only two weeks since my fundoplication and I have abslutely no chest esophageal pain or burning. The difficulty of swallow is getting much much better already. I think the major part of my orblem was the large hiatal hernia.

Good luck and God Bless.

ED







Quote:
Originally Posted by TigerGalLE View Post
So I went today for my 2nd opinion with a new ENT. He told me I had a better chance to win the lottery than to get throat cancer from my reflux. He said as long as I'm not a smoker I am not at risk. He also looked at my vocal cords again and said they looked healthy. He told me the surgery would not help me due to the fact that my problem is related to my esophageal dysmotility. He said to stay on my Nexium BID and to have an EGD every 4-5 years to make sure my esophagus stays healthy. He said esophageal cancer is more of a concern for people with reflux.

I'm so relieved to finally get some good news. I'm not sure why my other ENT was so sure I would end up with throat cancer. Hopefully this new guy is correct with his thinking. I wasn't going to have surgery anyway so at least this takes some weight off of my shoulders!

 
Old 10-04-2009, 08:03 AM   #12
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Re: Nissen for LPR? Is it really necessary?

Yea he told me I was at risk for esophageal cancer. My last scope was in July and I plan to get scoped every few years. My other ENT told me I was at a high risk for Layrngeal cancer and the only way for me to prevent it was to have a Nissen. My new ENT told me I'm only at risk for laryngeal cancer if I'm a heavy smoker. Which I'm not.
I never went and talked to a surgeon about having the surgery. I already knew I didn't want surgery and my new ENT helped me feel better about my decision. Doesn't seem like I'd be a candidate anyway with my esophageal dysmotility.

 
Old 10-08-2009, 12:51 PM   #13
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Re: Nissen for LPR? Is it really necessary?

Thank you very much for your informative post, Mountainreader

 
Old 11-15-2009, 01:22 PM   #14
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Re: Nissen for LPR? Is it really necessary?

hello ed,
My name is jade. I am 33 yrs old. I have been suffering from acid reflux for 13yrs. I have burning tongue, burning throat and acid at back of my mouth all the time. My symptoms make me feeling horrible all the time. I did all the tests(scopes, acid ph) and show i have a little acid stay in my oesophagus and my sphincter is a bit weak. I have tried all the antiacid medicines and none of them helped. The stomach spicialist told me I have sensitive oesophagus so they wont' let me do the surgery because he said surgery won't help. But in my opinion if they tighten up my sphincter my symptoms will go away. These syptoms are torturing me all the time. I can't enjoy my life at all. Please reply to me and let me know what symptoms did you have?
thank you,
jjade

 
Old 08-12-2010, 06:14 AM   #15
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Re: Nissen for LPR? Is it really necessary?

I had the Nissen fundipication July 21st, 2010.. my reflux was runnning & ruining my life.. I was eventually told that I was going to end up with throat cancer.. I had had the reflux for so many years.. that I can't remember when I DIDN"T have it!! Feeling miserable & not being able to eat the things that I wanted, & laying down to sleep at night.. not gonna happen. I had the lip of my esohagus stretched 2 years in a row. After the second time, my reflux was almost unbearable. I didn't know at the time that the stretching made it easier for the acid to come up. I went to Columbus, Ohio & Ohio State for my surgery. I was realyl scared, but knew I couldn't keep living that way. I am 3 weeks out, & going tomorrow for my recheck. I have seen that many of you can't burp, or vomit anymore, I was told that was a possibility.. but I have no problem doing either. I do get the gas, & have started using beano.. lol I had been taking 3 Nexuim a day, then was switched to 2 - 60 mg Dexilant a day, & 1 -150 mg Zantac.. still didn't help.. there are days that I get so frustrated, because I am hungry all the tme, but I know NOT to eat what I am not supposed to. I have paid for that several times, by it coming right back up. But on the upside, I weighted 150 & I am 5'4", I have already lost 20 lbs in 3 weeks, & I earned every one of those.. :} & I have no reflux symtoms anymore.. I no longer take any meds for reflux.. & I have had some people tell me that after they have quit smoking that things tasted different & smelled different.. that is what I have gong on with this surgery.. I have never been a smoker, but eveything tasted different, I like/love somethings that I didn't like before, & hate somethings that I loved.. I can't weight to get further out to be able to experiment to see all the different tastes out there that I have missed all these years. I am still pretty sore, & have the pains in the side, but it is still pretty new, & a pretty big surgery. I was going to get married in Sept but we moved it to Oct 2010. Good luck to anyone having the surgery. :}

 
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