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

[lpc]

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’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 problem.  Only time would tell.  In the six weeks since the surgery, the diarrhea has gotten better.  I seem to fluctuate between diarrhea, loose stools, and constipation . . . my body just hasn’t quite found the “happy” medium yet.  He said that the ability to vomit may return once the swelling goes down and the wrap loosens.  The flatulence is also related to the swelling and the wrap.  Since I can’t belch excess gas, that’s the only way it can exit my body.  It’s not really a problem, just an annoyance.  Right now, I’m avoiding foods that can cause excess gas (onions, broccoli, beans, etc.) as a way of controlling it.

The only other problem I’m still having is with the anemia.  After six weeks post-op, my hemoglobin count is only up to 9.0 (for women, the normal range is 12-16).  I can only assume that the ulcer isn’t bleeding since I no longer have black stools.  I’m taking iron supplements to help replenish my body’s store of iron.  Though I’m still concerned about the continuing anemia, neither the surgeon nor my regular doctor are, saying that it should be resolved over time.  However, after almost a year of suffering the consequences of anemia, they reassurances have fallen on deaf ears and I’ll probably still worry until my hemoglobin level is within normal range.

I hope this helps.  My case seems a little different than yours, in that you haven’t had the continued blood loss or severe anemia.  However, I never suffered through bouts of volvulus as you did.  Frankly, that scares me more than the bleeding, as the mortality rate is quite high when it’s acute and would make me want to go through with the surgery.  All I can say is that given the relatively minor problems I’ve had, undergoing the procedure was worth it.

[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