What is a Nissen’s fundoplication?

A Nissen’s fundoplication is an operation used to treat gastro-oesophageal reflux. It uses the top of the stomach to strengthen the sphincter so it is less likely to allow food, drink or acid to travel back into the foodpipe.

What is gastro-oesophageal reflux?

Normally, when we swallow food and drink, it moves down the foodpipe (oesophagus) to the stomach, where it starts to be broken down by the acids released from the stomach wall. After it has been partially broken down, it passes through to the small and large intestines, where all the goodness and excess water is removed.

When a baby or child has gastro-oesophageal reflux, the food and drink travels down the foodpipe as normal, but some of the mixture of food, drink and acid travels back up the foodpipe, instead of passing through to the large and small intestines. As the food and drink is mixed with acid from the stomach, it can irritate the lining of the foodpipe, making it sore. This is gastro-oesophageal reflux disease. Some children also breathe some of the mixture into the windpipe (aspiration), which can irritate the lungs and cause chest infections.

What happens before the operation?

Your child will need to come to the hospital the day before the operation for a pre-admission check. For more information, please see our Pre-admission clinic information. The doctors will explain the operation in more detail, discuss any worries you may have and ask you to give your permission for the operation by signing a consent form. Another doctor will visit you on the ward to explain about the anaesthetic. The doctors may also ask for some blood samples to check that your child is well before the operation. If your child has any medical problems, like allergies, please tell the doctors about these.

After the pre-admission check, you will be able to go home or stay in the Patient Hotel if you prefer, ready to arrive on the ward the following morning for the operation. Before you leave, the nurses will explain about fasting times for the operation. It is important that your child does not eat or drink anything for several hours before the sedation or anaesthetic. This reduces the risk of vomiting during and after the operation. After this time, your child should have nothing at all to eat or drink. You should follow these instructions exactly. Otherwise his or her operation will be delayed or even cancelled.

What does the operation involve?

At Great Ormond Street Hospital, most Nissen’s fundoplication operations are carried out using keyhole surgery (laparoscopy). The surgeon uses a telescope, with a miniature video camera mounted on it, inserted through a small incision (cut) to see inside the abdomen. Carbon dioxide gas is used to inflate the abdomen to create space in which the surgeon can operate using specialised instruments that are also passed through other smaller incisions (cuts) in the abdomen.

The surgeon moves the top of the stomach upwards and wraps it around the bottom of the foodpipe over the sphincter, securing it with stitches. This strengthens the sphincter, so that when the stomach is full of food, the top part wrapped around the sphincter automatically tightens to prevent reflux. It also stops the sphincter relaxing when it should be squeezed shut.
Depending whether your child is also having a gastrostomy, the operation lasts between one and two hours.

Are there any risks?

Every anaesthetic carries a risk of complications but this is very small. Your child’s anaesthetist is an experienced doctor who is trained to prevent and deal with any complications. Any surgery carries a small risk of infection or bleeding.

There is a chance that keyhole surgery will not be possible for your child. Sometimes the surgeon will not be able to carry out an operation using the keyhole method for technical reasons, or because of unexpected findings. If this is the case, the surgeon will carry out the operation using a larger incision (cut) instead.

What happens afterwards?

Your child will return to the ward to recover and his or her breathing, heart rate and temperature will be monitored closely for the first couple of days. After an anaesthetic, children sometimes feel sick, may have a headache, sore throat or feel dizzy, but these effects do not last for long.

He or she will usually have an intravenous infusion of fluids (drip) for a few days to allow the stomach to rest and heal. Strong pain relief medicines will also be given through a drip to begin with, but are gradually reduced and replaced with milder pain relief medicines given as tablets, liquids or suppositories when your child is eating and drinking again.
After keyhole surgery, some older children may complain of shoulder pain and some crackling under the skin, caused by the carbon dioxide escaping into the tissue just under the skin; this does not usually last long and gradually improves over a day or two.

If your child does not have a gastrostomy, he or she will have a naso-gastric tube for the first few days so that air and fluid building up in the stomach can be drained away; a naso-gastric tube is inserted through the nose, down the foodpipe and into the stomach. This is inserted while your child is asleep under the anaesthetic.

Your child will be able to drink when drainage from the naso-gastric tube or gastrostomy has slowed down and the fluid draining away is clear. As he or she gets used to drinking, small amounts of soft food can be added until your child is eating and drinking normally again. It may take up to two weeks for your child’s eating and drinking to get back to how it was before the operation.

Once your child is eating and drinking as normal and has recovered well from the operation, he or she will be able to go home. Most children stay in hospital for about three to five days after this operation. Your surgeon will tell you whether or not to continue giving your child any reflux medicines as previously.

Are there any long-term effects of the operation?

Although the Nissen’s fundoplication operation is very successful at improving a baby’s gastro-oesophageal reflux disease and the symptoms associated with it, a quarter of all patients develop some long-term effects afterwards, some of which we are able to treat.

• Changes in feeding pattern - The operation makes the stomach slightly smaller. For some children this can mean that they may need to have smaller volumes of feed given more regularly. The dietitian will advise you on how best to feed your child after the surgery.
• Burping and vomiting - After the Nissen’s fundoplication operation, some children are unable to burp or vomit. In some this is temporary, but in many this is permanent.
• Gas bloat - This is the name given to wind trapped in the stomach. It can usually be corrected by giving your child smaller feeds more frequently, rather than a few large feeds each day. If your child has a gastrostomy tube, the wind can be released by leaving it on the ‘reflux’ setting, which allows the wind to escape through the gastrostomy.
• Dumping syndrome - This is a combination of things including nausea, retching, sweating, diarrhoea and a drop in blood sugar level. It is caused by food travelling through the stomach at a much faster rate than usual so none of the goodness in the feed is absorbed. This can also be corrected by giving your child smaller feeds more frequently. These symptoms can take up to six weeks to settle.
• Recurrence of reflux - In some children, reflux symptoms can come back. This is because the Nissen fundoplication operation is failing (coming undone). Your surgeon may recommend that the operation be performed again.

What is the outlook for children with gastro-oesophageal reflux disease?

In some children, the symptoms associated with gastro-oesophageal reflux disease disappear with or without treatment, usually by the age of two. However, in some children, gastro-oesophageal reflux disease is more of a long-term condition and can have a serious effect on both the child and family’s quality of life. The options for treating gastro-oesophageal reflux disease are improving all the time, with new medicines and surgical options being discovered alongside a better understanding of why a child develops gastro-oesophageal reflux disease.

Most children see an improvement in symptoms, especially after the Nissen’s fundoplication operation, although some long-term effects may continue to be troublesome. Regular review during outpatient appointments is needed for most children until they are teenagers.

Source: UCL Institute of Child Health