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Gastroenterology  (Expert Forum)
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Elective Fundoplicaton for Paraesophageal Hiatal Hernia? Wise vs too risky?
Answered by
Kevin Pho, MD - Internal Medicine
Kevin Pho, MD Boston - MA
This forum is for questions regarding Gastroenterology issues such as Acid Reflux (GERD), Barretts Esophagus, Colitis, Colon/Bowel Disorders, Crohn's Disease, Diverticulitis/ Diverticulosis, Digestive Disorders, IBS, Stomach Pain.
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MedHelp Member's Question

Elective Fundoplicaton for Paraesophageal Hiatal Hernia? Wise vs too risky?

by lpc, Oct 10, 2005 12:00AM
I have been reading comments in several places in this medical blog about post operative complications of Fundoplicaton, because I am trying to make up my mind whether to have the surgery or not on a elective basis.  I have a paraesophageal hiatal hernia (PEH), but have had no overt major issues other than  1) frequent mild anemia presumably due to occasionally bleeding stomach (NO black tar stools), and  2) erosion of my stomach lining seen upon recent endoscopic examination, and 3) two medical emergency episodes of VOLVULOUS, five years apart --most recent was last month. (The GI doc at the hospital referred to it as my stomach 'flipping' or rotating to the point of causing severe crushing chest pain, vomiting quite a bit of 'coffee grounds blood' and 850 cc's of food and liquid being trapped up in my 'flipped' stomach which had to be removed with a therapeutic endoscope extension under general anesthesia.) It is important, I think, that these medical 'volvulus' emergencies occurred five (5) years apart.



I see in this blog that patients feel that the docs have oftentimes made fundoplications sound easy and unlikely to come with severe complications.  And yet many of your experiences have proved otherwise. (e.g., Damaged vegal nerves, dysphagia, severe nausea where you cannot vomit, and all the rest that I am reading about.)



That is why I am writing.  I need to hear more about this -- how often in fact do these types of complications occur - especially with a PEH as a complicating issue?  



BOTTOM LINE, DO THE SERIOUS COMPLICATIONS OR AFTER-EFFECTS OF FUNDOPLICATION OCCUR OFTEN ENOUGH, SO THAT THE 'THINKING INDIVIDUAL' SHOULD THINK TWICE BEFORE ELECTIVE FUNDOPLICATION, PARTICULARLY WHEN WE HAVE PARAESOPHAGEAL HIATAL HERNIA AS THE DIAGNOSIS??? This is a crucial question for me.



I have seen two well respected laparoscopic surgeons.  One said he would not touch this one, because he says he does not have enough experience with PEH and its frequent complications - particularly since my stomach is fully intrathorasic (is that the word for fully in your chest?)  He AND the local medical school referred me to the surgeon who is supposed to be the 'Top Gun' in the Dallas area in doing this type of surgery.  Much to my confusion, that surgeon downplays the likelihood of major complications, and makes it sound like the surgery is run of the mill standard. But what I am reading does NOT sound like that is the case.



Big Question:  Am I playing with fire to undergo this type of surgery when I have had only one medical emergency in the past 5 years related to volvulus (last month)?



NOTE:  I HAVE ONLY RECENTLY (SINCE THE RECENT MEDICAL EMERGENCY WITH THIS) STARTED TO FOLLOW A LOW-RESIDUE DIET AND LIFESTYLE CHANGES SUCH AS NOT EATING AT 10:30 AT NIGHT. AND I FEEL FINE AT THE MOMENT. SHOULD I TRY THIS APPROACH BEFORE JUMPING INTO FUNDOPLICATION?



All comments including that of the doc here, are welcome and encouraged!  Thanks sincerely
Doctor's Answer

by Kevin Pho, MD, Oct 11, 2005 12:00AM
The complications for a fundoplication would depend on the severity of the hernia as well as the skill of the surgeon in question.  Obviously, the chance of complications or success would vary.  That being said, it is difficult to give an accurate rate without reviewing your case personally.



There are various degrees of paraesophageal hernia.  The most common type (based on the characteristics of the hernia itself), has a surgical success rate of about 80 percent - with recurrence happening in about 15 percent.  



If there continues to be conflicting opinions on the operative risk, I would suggest continuing to obtain opinions until you feel comfortable with the surgical risk.



Followup with your personal physician is essential.



This answer is not intended as and does not substitute for medical advice - the information presented is for patient education only. Please see your personal physician for further evaluation of your individual case.



Kevin, M.D.

http://www.straightfromthedoc.com
Member Comments

by Catherine53, Oct 26, 2005 12:00AM
To: lpc
Here’s my story from diagnosis to post-op:



In late April 2005, after putting off going to the doctor for months about my shortness of breath, heart palpitations, lightheadedness, muscle cramps, black stools, and general fatigue, I finally couldn’t take it anymore and made an appointment.  Among other tests, he did a complete blood count, which showed that I was severely anemic (my hemoglobin count was 5.8, a level which I’m told is critically low).  He sent me immediately to the ER, where I ended up getting three units of blood and was admitted into the hospital for a battery of tests (an endoscopy, a colonoscopy, and a barium swallow) to discover the source of the blood loss:  It was determined that I had a large paraesophageal hernia and a bleeding ulcer.  I was also diagnosed with gastritis, given a subscription for Prilosec, told to follow a bland diet, take iron supplements, and not to take any NSAIDs.



NOTE:  I should also mention that I’ve suffered with GERD intermittently for about 10 years.  My symptoms included acid regurgitation while in bed, a persistent cough while sleeping, hoarseness, sometimes difficulty swallowing (both solid and liquids), and food sticking in my esophagus.



After the transfusions, my hemoglobin level got up to 10.8.  My gastroenterologist referred me to a surgeon in my HMO who handles, as the surgeon put it, “the tough cases,” including redoing the fundoplication procedures done by others, but which had come undone or otherwise needed redoing.  He said that in my case, he didn’t know if he’d be able to perform the Nissan fundoplication laparoscopically or open, that he’d only find out once he’d started the actual procedure.  He explained the procedure to me and assured me that many of the difficulties that people used to have with it (i.e., inability to vomit, dysphasia, bloating, etc.) were no longer problems.  He said that surgeons are now careful not to wrap the fundus as tightly around the esophagus as had been done in the past, that they now do a “floppy” wrap.  However, rather than perform the procedure immediately, the surgeon wanted me to give the ulcer some time to see if lifestyle changes (and Prilosec) would resolve the bleeding without surgery.



After nearly four months of intermittent bleeding, my hemoglobin level dropped back down to 7.9.  By then, I’d done quite a bit of research on the procedure, plus my specific problems, and was able to persuade the surgeon to go ahead with the surgery.  He admitted that surgery was the only way to resolve the ulcer which was caused by pressure being exerted on the stomach by the hernia.  He said that, given the continued bleeding, I was running the risk of the ulcer perforating my stomach, which could prove fatal.



In early September 2005, the surgery was performed.  Because of my low hemoglobin level, two units of blood were administered.  The surgeon was able to correct the hernia and perform the Nissan fundoplication laparoscopically.  I was only kept in the hospital overnight.  Before I left the hospital, I was given clear liquids to ensure that I didn’t have a problem with dysphasia (I didn’t).  While I had some pain, it was readily controlled with Lortab Elixir, which is a liquid form of hydrocodone.  The pain gradually abated by the second week.  After three weeks, I returned to work, though I was on half-days (my choice) for the first two weeks.



For the first couple of days, I was on clear liquids, followed by two weeks on full liquids, then two weeks on soft foods.  Solid foods were gradually introduced after that.  I’ve never experienced any problems with anything sticking in my esophagus or difficulty swallowing.



The only problems I’ve had are intermittent diarrhea, the inability to vomit, and flatulence.  The surgeon said that diarrhea is a common problem after GI surgeries, and that it should get better in 2-3 months.  However, he also said that it could “become a part of me,” or in other words, be a chronic