Slipped Nissen Wrap

Slipped Nissen Wrap

Tom from Conroe, TX sent us this question: “Would a slipped Nissen wrap be visible on a CXR and would it cause extreme shortness breath that is not due to heart or lung conditions?”

Dear Tom,

Slipped Nissen wrap is a recurrent hiatal hernia; the stomach “slips” through the fundoplication or wrap and it herniates back into the chest. This finding can be easily identified on CXR. A slipped Nissen wrap is almost always a direct result of poor esophageal mobilization during initial surgery. Symptoms associated with slipped Nissen fundoplication range from mild chest discomfort to severe heartburn and inability to swallow food. Shortness of breath may result from a slipped Nissen fundoplication, aka recurrent hiatal hernia. Shortness of breath may be precipitated by a heavy meal or gas accumulation in stomach. Obviously, shortness of breath is worse with a larger herniated stomach size.

If slipped Nissen fundoplication is suspected on CXR, additional diagnostic studies like UGI and upper endoscopy are indicated to evaluate the size of the hernia, associated pathology, state of wrap… Surgical revision is indicated in the form of redo hiatal hernia with or without mesh placement and redo Nissen fundoplication. Surgical revision, in experienced hands, has a high success rate. It is important to properly address the root cause of hiatal hernia recurrence to prevent a second wrap slippage. The root cause of slipped Nissen fundoplication is poor esophageal mobilization as I initially mentioned.

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