Slipped Nissen Fundoplication: Why Do We Still See It?
Nissen fundoplication surgery, when PROPERLY done, is the most reliable, safest, and most effective treatment for GERD. Any fundoplication surgery is performed with a concomitant hiatal hernia repair. The purpose of a hiatal hernia repair is not to simply close the hiatal opening, but rather restore normal anatomy. Normal anatomy consists of 3 to 4 cm of intra-abdominal esophagus without any tension. It is a common misconception among general surgeon to suture fixate the gastroesophageal junction (GEJ), and fundoplication below the diaphragm. Such mechanical fixation is futile in the face of a dynamic structure like the GEJ. Indeed, GEJ is constantly moving up and down with breathing, coughing, and swallowing. GEJ is a MOBILE anti-reflux barrier. Any surgical intervention that does not fully mobilize the GEJ is bound to fail in the early post-operative period or shortly thereafter.
Such failure presents in the form of slipped Nissen with or without recurrent hiatal hernia. Slipped Nissen fundoplication is the axial movement of the esophagus back into the chest due to poor mobilization. Such axial movement drags the GEJ and upper part of the stomach through the fundoplication, hence the term slipped fundoplication. The fundoplication itself can move up into the chest through the hiatal opening resulting in recurrent hiatal hernia. Patients typically present with recurrent acid reflux with or without esophageal obstruction causing dysphagia.
The diagnosis of slipped Nissen fundoplication is made using a combination of upper endoscopy and UGI contrast study. On EGD, gastric mucosa looks pouching above the wrap and on UGI an hour glass appearance may be detected. The treatment consists of surgical exploration, reduction of hiatal hernia, esophageal mobilization, redo fundoplication and hiatal hernia repair.