Dr Harris from Humble sent us this question: “What is the durability of Nissen fundoplication in Your Experience? In literature is written that after 10 years Nissen loses efficacy I am a family doctor affected by LES incontinence since 1993. Thank you.”
Dear Dr. Harris,
Heartburn puts a damper on enjoying life to the fullest. It’s essential to address it and find ways to manage or alleviate it so you can focus on the things that truly matter to you. Lower esophageal Sphincter (LES) pressure is an important component of the antireflux barrier. LES pressure is measured using manometry. Esophageal manometry is a simple outpatient test that we offer at Houston Heartburn and Reflux Center. A low pressure LES on manometry indicates a weak antireflux barrier that results in severe acid reflux symptoms. The most reliable solution for a weak LES is Nissen fundoplication. A properly performed hiatal hernia repair and Nissen fundoplication restores the antireflux barrier and prevents any backflow of gastric content into esophagus.
The durability of Nissen fundoplication greatly depends on surgical technique, and health of tissues that are sewn together to construct the wrap and close the hiatal hernia. Acid reflux causes inflammation and tissue destruction around the gastroesophageal junction. Reconstructing the acid reflux barrier with weak tissues is not likely to last very long. Similarly, age and smoking further weaken the repair and decrease durability. The most frequently cited paper for long-term follow up of Nissen fundoplication patients was published in in 2001 by Spechler et al in JAMA (Journal of the American Medical Association). Of the original 247 patients that participated in the study, 239 were found. 79 patients were confirmed dead mostly from heart disease. Among the 160 survivors, 129 participated in the follow up (91 in the medical group and 38 in the surgical treatment group). Of note, the subjects included in the study had advanced GERD with esophageal ulcers, stricture, and or Barrett’s esophagus. Average age at the time of surgery was 58 and 50% of subjects were smokers.
The authors concluded that after a mean follow up duration of 10 years, 23 out of 37 Nissen fundoplication patients reported use of proton pump inhibitors. Hence, there is no advantage of Nissen fundoplication over medical therapy. Although the study is underpowered for any meaningful conclusion, it has been adopted by many gastroenterologists and primary care physicians in Houston as a treatment guideline for GERD.
Our experience at Houston Heartburn and Reflux Center is different. With over 1000 consecutive Nissen fundoplications over the past 10 years we have achieved 100% success rate in eliminating GERD related symptoms and improving quality of life. At the same time, our complication rate is zero. Our postoperative dysphagia rate is zero, and our patient satisfaction rate is very high. So far, we have not had any patient presenting back to Houston Heartburn and reflux Center with recurrent GERD or failed Nissen fundoplication. Our experience strongly supports early surgical intervention not only to prevent the development of GERD complications like Barrett’s esophagus, esophageal stricture and ulcers, but also to enjoy a reflux and heartburn free life.