Persistent Heartburn after Nissen Fundoplication
Paula from Houston sent us this question: “Just had Nissen fundoplication surgery still having heartburn surgeon gave me an upper endoscopy said I’m not having reflux its anxiety. I don’t know what to do”.
Heartburn is a symptom. Acid reflux is a disease. The gold standard diagnostic tool for acid reflux is ambulatory pH testing that measures esophageal acid exposure over a number of days. Heartburn is the most common symptom of acid reflux. However, patients may feel heartburn in the absence of acid reflux disease. You may have a hypersensitive esophagus. Stress and anxiety do not cause acid reflux to happen but increase esophageal sensitivity to acid reflux.
Nissen fundoplication patients who report persistent or new onset heartburn after surgery need to be evaluated with upper endoscopy and ambulatory pH testing. An acid reflux specialist uses upper endoscopy to evaluate the anatomy of the gastro-esophageal junction and rule out recurrent hiatal hernia or loose wrap. Furthermore, upper endoscopy visualizes distal esophageal lining to check for acid reflux induced inflammation or ulceration. The addition of ambulatory pH testing increases the sensitivity and specificity of testing and effectively rule in or out persistent or recurrent acid reflux disease after Nissen fundoplication.
By the same token, upper endoscopy and ambulatory pH testing are used prior to Nissen fundoplication surgery to confirm acid reflux disease. Patients who don’t have acid reflux disease will obviously not improve after Nissen fundoplication and continue to have whatever symptoms they suffered from prior to surgery.
To summarize, pre-operative acid reflux work-up and patient selection are important aspects of acid reflux treatment. Patients with confirmed acid reflux disease have a very high success rate with a properly performed Nissen fundoplication. Patients with persistent or recurrent acid reflux symptoms after Nissen fundoplication need to be evaluated by an acid reflux specialist. I am completely against the blind use of proton pump inhibitors after Nissen fundoplication without confirming recurrent acid reflux disease. Revision Nissen fundoplication surgery is offered to patients with a disrupted wrap, or recurrent hiatal hernia with good outcome.