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

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

[Kevin Pho, MD]

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

[Catherine53]

Here

[lpc]

Thanks, Catherine, for your response to my posting. As you can see, you are the only person aside from the doc who has responded - and I would think that this is because this is such a rare condition.  One question - was your stomach fully into your chest, or only partially?  Mine is 100% into my chest up behind my heart, and I am told that (based upon the CT scans) there are probably something 'like' adhesions (but not actually adhesions) which are connecting part of my heart and lungs to my stomach, which would need to be dealt with and could be problematic when the stomach is moved down.  That scares me because it intoduces another opportunity for serious post-op infection.  Especially with the heart.  

I have an appointment with a gastroenterologist later on this month.  One main question that I have for her is, is it possible for volvulus to occur without my being aware of itin time to seek successful emergency intervention?  Certainly the last time this occurred I was in tremendous pain and knew immediately that something bad was going on, and this to the ER for emergency intervention. But I want to be sure that this potentially fatal complication cannot occur 'silently'.  That will certainly be the main thing for me to consider, in deciding to move toward surgery.  I do not have severe anemia -- just down in the 10-11 range when I am not on iron, and no black stools. And no ulcers although there is a lot of erosion in my stomach (not my esophagus).  So I don't have those two issues that you had.  Thanks again for your input.  It makes me somewhat less wary, in the event that it seems that I need to move forward with this.  Much appreciated, Catherine! - lpc

[Catherine53]

lpc -- Just noticed your question to my response.  As to how much of my stomach was above my diaphragm, I've gotten two different descriptions.  Right after the endoscopy was performed, the gastroenterologist told me that I had a large hiatal hernia, with two-thirds of my stomach above my diaphragm.  He didn't change the description after seeing the films from my barium swallow test.  However, when I saw the surgeon for the initial consult and mentioned the GI doctor's description of my problem, he said that it was less than two-thirds.  It was the surgeon who first described the hernia as being paraesophageal.  He didn't mention anything about adhesions. Frankly, I never pushed the discrepancy between the two different diagnoses, i.e., size of the hernia.  I just knew that I had a bleeding ulcer that wasn't getting any better.

It's been almost three weeks since I last posted and thought I'd give an update.  Am still having problems with diarrhea and am wondering if it's going to be chronic, which I've since read can be common with any gastric surgery.  I'm afraid that I've gotten too complacent about my diet, as I've started having problems with stomach cramping.  I'm almost wanting to revert back to a soft diet for a while . . . red meat, chicken, and even steamed veggies aren't sitting too well.  It may also be related to lots of stress I'm under at work, trying to play catch-up.  I may also need to go back to multiple small meals per day.  I won't know whether or not the anemia is getting any better until my next scheduled blood tests in December.

Again, hope this helps.  If you have any more questions, I'll try to answer them if I can.  Good luck with your consult and hope everything works out.

[lpc]

Hello.  Just now saw your latest response (I got no email notification -- just went into the site and saw your response - thanks!)  I am wondering about the inability to vomit, and am confused about whether surgeons expect that to usually be a permanent side effect of fundoplication for most people, or just a temporary one which MAY be permanent in most people.

There is the obvious reason to be worried about this if it is a permanent thing (i.e. what do you do when you have a GI virus and ordinarily would be 'vomiting your head off' and you feel deathly ill until you can get all that stuff out?).  

But mainly I am concerned because vomiting up blood (both fresh and 'coffee grounds' partially digested blood) has been the ONLY thing that finally got the ER people to say "OH! Maybe this isn't a heart attack that is causing this pain -- it must be something gastric so we better switch gears here."  Which is what saved my life this last time - abandoning the 'heart attack' train of thought. And obviously this would be critical if my stomach does another volvulous (which apparently can re-occur in some people even after fundoplication).  If the ER folks don't have bit of insight, I could die from strangulation.

Also, did you have a full wrap or a partial wrap, and if a full wrap, did you doctor say why he was going to do a full instead of a partial?  And did he say anything about doing a 'tension-free' fundo?  Thanks so very much.  - lpc