Gerd to Fundo to Doubts.. can you help..?
 

For several years now i have had a constant soar throat,( never any heart burn ) and this problem was diagnosed as being due to reflux acid and LPR, the endoscope and biopsys also showed Barretts esophagus ( low desplasia)
and chronic gastritis, and for 18 months i was put on a high dose of Ranitidine, Domperidone, Omeprazole and nexium. ( 12 tablets a day )
which over the 18 months I took them , made the soar throat feel a bit better but not go away completely, my doctor then recommended that I have further tests to evaluate the possibility of having a Nissen laparoscopic fundoplication
The tests he recommended were , a mamometry test , a 24 hour double probe Ph test, along with a barium meal swallow test.
The problem was that the recommended tests were not available where I live (in Thailand where the doctor said that Thais do not seem to get barretts esophagus / reflux acid problems , due he said to the fact of the Thai diet and the Thai's drink large amounts of water every day...? ) . so i took the decision to fly to europe to obtain further tests to confirm my situation.
The tests confirmed that I had a weak LES, and high numbers of acid reflux episodes over a 24 hour period. The doctors recommended that due to the fact that the high dose of drugs I had taken for 18 month's, had not seemed to completely reduce my throat problem and the fact I had Barretts Esophagus , a Nissen Laparosocpic Fundoplication would be the best option.

So i went ahead with the surgery, I was admitted to hospital at 8.pm Friday night , and discharged on Sunday 11am, The operation went well, The surgeon had outlined the possible after effects of the surgery, such as gas bloat, chest pain due to traped air, etc, and he gave me a run down on the post op eating requirements. He said a full wrap had been carried out , which was stiched to the esophagus to stop the wrap from turning he also said he had used a " bloon probe " inserted down the esophagus to gauge the correct tension of the wrap around the esophagus. In his words he had done a " loose" type of wrap , as this was considerd the best option ,he also advised me to only take 40mg of Omeprazole a day for one month after the surgery.
All went well and I have now returned to Thailand, but now back home , away from the comfort of knowing I could easily contact the Doctor who carried out the surgery, I am starting to have my doubts !!!, here's where I hope forum members can offer me some advice or comments.
First I know its only been 5 weeks since I had the surgery, and may be I am just panicking too soon ?.... heres my doubts ...
1. A week after the surgery my soar throat seem to be getting better, I thought great, the wrap has started to do its job..?, on returning home Two weeks later , my old enemy the soar throat has returned and feels worse than before the surgery ( this includs the same symptoms of a soar,red and what appears to be small blisters on the back of the throat area ).... so with the symptoms returning this makes me now think....... , could it be that the loose wrap was done was in fact... too loose, this combined with me now only taking a small dose of Omeprazole(may be not enough to control the acid ..?) this has now allowed the acid to return to my throat area again to a greater degree ...?
2. Or could it be the my soar throat has returned due to a miss-diagnosis in the past , and in fact there's some thing else comming into play that's effecting/causing my soar throat .
3.Or could it be the soar throat has returned due to some sort of post re-action to the surgery...?( and hopefully will get better in the future..? )
4.The doctor also recommended having an endoscope/biopsy done 6 months after the surgery,.... would it be possible from the endoscope to tell if the wrap is at the correct tension...? and working as it should do...?
may be I am just over reacting and jumping the gun , but from just having my old soar throat symptoms return in what seem's a worse state , stright after undergoing the surgery makes me wonder if its all been worth it , and as medical advice on my condition is difficult to obtain here in Thailand, I can only hope forum members can may be offer some advice to enable me to decide just where to go from here. Many Thanks,

Re: Gerd to Fundo to Doubts.. can you help..?
 

Hi there - I'm not sure I can answer your questions, but I can offer my support as a fellow fundo patient. I had mine done in 2001 - also a tight wrap, and I have never had a return of the sore throat from reflux, the coppery taste in my mouth, the burning sensation or the re-tasting my meals with every belch. So maybe your wrap isn't tight enough. Can you burp easily or vomit? (I'm sorry to be gross here).

The reason I ask is that whenever I've gotten sick, I have only had the dry heaves - I cannot vomit anymore. Burping is difficult too and sometimes I have to just sit and wait for several minutes to relieve the gas. This is all because of how tight my wrap is. I don't mind since it has protected me from worsening of my Barrett's. In fact, mine was caught early enough that the biopsies done since surgery have all been "clean." I had endos done annually since surgery, and the last one was this year - I now can wait for 3 years before I'll need another one. So keep up with the endos as scheduled to monitor your situation.

You might want to call or e-mail your surgeon with your concerns. The wrap may not be tight enough for you - or you may have a different problem causing the sore throat. I'm sorry I couldn't be more help.

Good luck to you,
Katie G

Re: Gerd to Fundo to Doubts.. can you help..?
 

Kate G , Thanks for your reply - one of my main problems living here in Thailand has been getting sound medical advice about my condition. This is why I decided to go to Europe to have further tests before having the surgery carried out there . Yesterday I went back to see my Thai Doctor to outline my situation after the surgery I told him about the surgon doing a " loose " wrap, and that I still have a bad throat.
The doctor thought yes my bad throat may be due to the wrap not being tight enough, or the wrap stiches comming undone he has recommended that I have a barium meal swallow X-ray to try and see what's going on..? my current throat symptoms are identical to the symptoms I had before the surgery. As for my diet I am still following the " normal " reflux diet, no spicy foods, no fizzey drinks, no orage juice, no coffee, no alcohol etc. I did ask my Thai Doctor about having a new endoscopy and he said first have the berium meal X-ray then let's see . ( also there's no facility here to have a 24 hour Ph test or a manometry test) He also said if the X-ray showed continuing acid reflux then I would have to start a new programme of drugs again ( which is why I decided to have the surgery in the first place) He did say if I had to start again with drugs, he wanted to try a " new" drug thats come onto the market from England ...? (I did not get its drug or brand name yet ) As for contacting the surgeon in Europe who did my operation, I do have his e.mail address, but I want to wait a bit to see just how things progress rather than jumping the gun and telling him about my present condition , and then it changes in due course .
The thought of having to fly a 15,000 mile round trip again and going through a second operation is some thing that I would be happy not to have to do !!. .
After the X-ray berium test next month, I will let you know the results and what my Thai Doctor has recommended, thanks ..... Star

Re: Gerd to Fundo to Doubts.. can you help..?
 

HI Katie, just forund this on the web.......... 1. The surgeon performing the operation is faced with a difficult
dilemna. He knows before starting the procedure that if the wrap is
too loose, then the reflux symptoms will persist after the operation,
which will result in an unhappy patient. Conversely, if the wrap is
too tight, symptoms of gas, bloating, and inability to belch will be
major problems. For each case, therefore, the surgeon makes a mental
trade-off between these outcomes. Experienced surgeons, can usually
know the tightness of the wrap based on factors such as body size and
preop gas symptoms but this decision is often more a reflection of
the art of surgery than the science.
2. Fundoplications are the most widely used form of antireflux
surgery. Similar results have been obtained irrespective of whether
the procedure is performed using an open conventional laparotomy
approach or with the use of modern laparoscopic technology. Since the
introduction of the Nissen total fundoplication procedure, there has
been some concern about the incidence of troublesome mechanical
complications, which occur in about 15% of cases. The most frequent
postfundoplication symptoms are dysphagia, inability to belch and
vomit, postprandial fullness, bloating and pain, and socially
embarrassing flatus. The frequency which these symptoms have been
reported varies considerably among series. Dysphagia is frequently
reported during the early postoperative period, but seems to diminish
with the passage of time, as do other post fundoplication symptoms.


3. Anti-reflux surgery establishes or restores the anti-reflux
barrier and corrects other abnormalities that may be conducive to
reflux events. An adequate procedure reduces esophageal acid exposure
time, but does not necessarily eliminate symptoms. The explanation
for persistent or new symptoms after surgery can usually be
classified into one of four categories, although establishing the
precise explanation is not always straightforward. These categories
are: (1) inadequate correction of gastroesophageal reflux, (2)
persistence of a functional esophageal syndrome, (3) development of
symptoms related to the anti-reflux procedure itself, and (4)
persistence of symptoms that were unrelated to reflux disease or
esophageal dysfunction from the beginning. As a general rule, the
best outcome can be predicted if pathological reflux can be
demonstrated on amublatory pH studies, the primary symptom is typical
of GERD, and a good clinical response occurs with acid suppression
therapy (1). When any of these criteria are absent, the likelihood of
postoperative symptoms climbs.
The first of the four stated mechanisms is the simplest to determine,
because ambulatory pH monitoring can reliably establish the degree of
esophageal acid exposure and reveal the adequacy or inadequacy of the
anti-reflux operation. Technical problems with pH monitoring, correct
positioning of the pH probe, and patient discomfort are the most
important factors in the utilization of these methods. Failure to
adequately control reflux occurs in as many as 20% of patients and is
more likely at one year after a partial wrap than a complete Nissen
procedure (2,3). Persistently abnormal esophageal acid exposure time
remains the most common reason overall for re-operation (4).
Consequently, this explanation for failure must be considered in all
patients with persistent post-operative symptoms.
The presence of a functional esophageal syndrome is more difficult to
establish pre-operatively but is a common explanation for persistent
symptoms. Functional esophageal syndromes often complicate reflux
disease, as acid reflux events are considered important provoking
factors in the pathophysiology of these disorders. At present, both
motility abnormalities and visceral sensitivity are thought to
participate in these syndromes. Spastic motor disorders and increased
sensitivity to intra-esophageal balloon distention are important
markers, but no physiological measurement is sufficiently sensitive
nor specific to be uniformly clinically useful. The best clinical
indicator is the persistence of symptoms following adequate medical
treatment, and refractory symptoms, unresponsive to medical
treatment, are recognized as predictors of poorer outcome from anti-
reflux surgery.
Symptoms related to the surgical procedure itself may mimic some of
the presenting symptoms, as the repertoire of esophageal symptoms is
quite limited. For example, dysphagia from reflux disease, e.g., the
non-obstructive dysphagia reported by some patients, may be replaced
by dysphagia from a fundoplication. The two may not be differentiable
by the patient. Painful swallowing resulting from an obstructing
fundoplication may resemble chest pain related to reflux preceding
the operation. Objective data are often more important in the post-
operative setting for correct attribution of symptom origin.
Finally, some symptoms are unrelated to reflux disease, were thought
to be a part of the reflux syndrome, and fail to respond to anti-
reflux surgery. The most typical example is the group of "atypical"
reflux symptoms, such as ENT or pulmonary manifestations. It is
difficult to fully establish a direct relationship of such atypical
symptoms in the preoperative setting, and response to medical
management is also difficult to interpret in these situations
[although response to medical therapy remains one of the best
predictors of response to surgery even for atypical symptoms (6)].
Chronic cough has a notoriously poor relationship to reflux events on
ambulatory pH studies, even when the symptom is directly related to
GERD [but a good preoperative association remains a predictor of good
surgical outcome (7)]. Only after successful anti-reflux surgery,
when acid exposure time is markedly reduced and other, non-acid
reflux events are eliminated, can the relationship of reflux to the
symptoms be fully appreciated - and then the therapeutic trial may
prove a failure. Data continue to accumulate demonstrating the
benefits of anti-reflux surgery on atypical symptoms or unusual
symptoms that may be clustered with heartburn and regurgitation (such
as nausea), but the best indicator of success continues to be
excessive reflux on an ambulatory pH study and a statistically
significant association of the symptom with reflux events.
4.currently a loose floppy Nissen is the standard of care for open
or laparoscopic Nissen Fundoplication.
5. Several authors have addressed the issue of failed
fundoplications. Patients may complain of new symptoms or persistence
of old symptoms. Some degree of mild symptomatology may be normal or
at least expected in the early postoperative period, and it is
reasonable to treat these complaints with reassurance, medical
management, and tincture of time. An early barium swallow can serve
to reassure both the patient and the surgeon that there are no gross
anatomic flaws with the wrap. Waring asserts that if both a barium
swallow and an EGD demonstrate an intact fundoplication, both early
heartburn and dysphagia will usually resolve. Symptoms persisting for
more than 6-12 weeks, or symptoms that are very debilitating to the
patient, need to be pursued more vigorously.
6.Recurrent GERD symptoms.
When recurrent or new symptoms develop in the late postoperative
period (greater than three months) investigation is warranted. For an
individual who returns with symptoms identical to those for which
they underwent their operation, a diagnostic trial of antireflux
medication is appropriate. In addition, we generally order a barium
swallow, as we have determined that at least 90% of all
fundoplication abnormalities can be seen with this study.10 If the
barium swallow is normal (i.e. the fundoplication is intact), it is
unusual for patients to respond to proton pump inhibitor therapy. In
this case, the most frequent explanation for the occurrence of
recurrent symptoms is that the symptom reported is a result of a
problem distinct from gastroesophageal reflux. Because respiratory
symptoms and atypical gastroesophageal reflux symptoms are so often
intertwined, it may take the performance of a fundoplication to
determine which superesophageal symptoms are related to reflux and
which are not. The best predictors of superesophageal symptom relief
after a fundoplication are the response of the symptom to proton pump
inhibition, and/or the correlation of superesophageal symptoms with
reflux events on a 24-hour pH study.
If preliminary evaluation with a postoperative barium swallow does
not reveal any abnormalities, and a trial of medical therapy fails,
further investigation is unlikely to bear fruit, but should be done
nevertheless. In 10% of our patients referred for postoperative GERD
symptoms, an EGD revealed an anatomic problem missed by barium
swallow.10 The most common anatomic problem discovered on EGD when
the barium swallow looked normal was a slipped or misplaced Nissen
fundoplication.


The more I find out about my present condition the more confused I
become ... ? any comments always welcome .........

STAR........

Re: Gerd to Fundo to Doubts.. can you help..?
 

Wow - that's a lot of information to absorb!!! However, what I understood from it is that my residual symptoms/condition of difficulty belching and inability to vomit are the result of a tight wrap, even though some surgeons prefer to do a loose wrap.

My surgeon had informed me prior to surgery that due to my Barrett's, he wanted to insure that my reflux would be stopped, and that since my lower esophageal sphincter was weak (as measured per esophageal manometry), a loose wrap would not necessarily stop the reflux from occurring. I did not want to have to keep taking PPI medication for the rest of my life; therefore, I opted for the fundo instead. I have not returned to any anti-reflux med since.

In your case, I guess you need to follow the doc's recommendation for a barium X-ray first, and then possibly consider the medication. I can understand your difficulty with that, since you had the surgery to stop the reflux and be able to discontinue the medication. However, a tighter wrap has its disadvantages too - as I've already experienced.

Your quality of life is the most important measure. If your doctor wants to do additional testing prior to deciding if further surgery is warranted, then that's probably the best way to go. If medication + the loose wrap will control your condition, and you are satisfied with that course of action, then that may be the best alternative. I'm sorry to be so wishy-washy, but every fundo patient needs to decide for themselves what kind of life quality they want. I had to learn to adjust to a new way of eating/drinking since the fundo, and still have episodes of painful gas and inability to vomit. But I can live with that if it keeps my reflux under control.

Good luck and keep us posted,
Katie G