Recurrent Heartburn after Nissen Fundoplication
Laparoscopic Nissen fundoplication is the most effective and reliable treatment for acid reflux disease. Nissen fundoplication durability is very high when workup and surgery are performed by expert reflux specialists. Therefore, most patients who present with recurrent or persistent heartburn after a properly performed Nissen fundoplication do not have recurrent reflux. Heartburn is a symptom; acid reflux is a disease. A symptom is a subjective complaint reported by patient; a disease is objectively confirmed by appropriate testing. You may feel heartburn in the absence of reflux. At Houston Heartburn and Reflux Center, we recommend repeat upper endoscopy with ambulatory pH testing to rule out recurrent reflux following laparoscopic Nissen fundoplication. I reviewed our patient data at Houston Heartburn and reflux Center over the past 3 years. 4 patients presented after Nissen fundoplication with recurrent heartburn. All 4 patients were found to have intact fundoplication, no recurrent hiatal hernia and negative pH bravo study for acid reflux on repeat upper endoscopy and ambulatory pH testing. Anxiety and stress seemed the precipitating factor in recurrent heartburn in 3 patients. One patient’s son attempted suicide. Following this unfortunate event, patient started feeling heartburn, sore throat, food regurgitation. Such symptoms are highly suggestive of recurrent GERD. The unexperienced physician may rush and wrongly start patient on proton pump inhibitors, PPIs. However, without proper testing, and in the absence of a confirmed diagnosis of recurrent GERD in the setting of a failed fundoplication, such approach is wrong. Interestingly, some patients may respond to PPI treatment for recurrent heartburn in the absence of recurrent reflux due to a placebo effect. Most of these patients will end up spending the rest of their lives taking a medication for the wrong indication. Long-term PPI use is associated with serious side effects including kidney and heart disease. Committing patients to PPI therapy without GERD diagnosis is best avoided.
The second cause for recurrent heartburn in the setting of absent reflux following Nissen fundoplication is heart disease. The fourth patient presented to Houston Heartburn and Reflux Center, one year after Nissen fundoplication with burning epigastric pain, bloating, maldigestion and the feeling of food regurgitation. He had shortness of breath at night and he was sleeping with the head of bed elevated. Work up showed a dilated heart on CXR and low ejection fraction on echocardiogram. He was diagnosed with congestive heart failure due to viral cardiomyopathy. Lasix rather than Protonix was the appropriate treatment. Heart disease and GERD have overlapping symptoms. Differentiating both diseases before or after laparoscopic Nissen fundoplication is crucial. We maintain a high index of suspicion for heart disease especially in high risk patients presenting for GERD evaluation. Risk factors for heart disease include smoking, hypertension, type 2 diabetes, obesity and hypercholesterolemia as well as a sedentary lifestyle.