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  • Fundoplication Re-Do's

    Today was 3 months post op for my 2nd fundo, and I am still in recovery mode - no surprise there. My energy is getting better and I am able to maintain a pretty much normal activity level without feeling too pooped. (Although, I must admit, I'm not ready to take on anything too strenuous. ) I am continuing to eat a lot of GasX and Pepto Bismol due to digestive system upheaval and seem to suffer with gas, bloat, nausea, and/or diarrhea probably 4+ days a week - but even that is better than it was just a few weeks ago. I am also taking digestive enzymes to help settle my system down - not sure if they are making things better, but I have improved since I started taking them.

    I am still on Prevacid - 30mg 2x a day. I have an appointment with my new GI doc at the University of Maryland Medical Center next week - I ditched my GI doc at Hopkins after my first fundo failed. I plan to talk with this new guy about some issues I am having and how long I should continue the meds.

    Before the second operation, my surgeon, Dr. Adrian Park, talked at length with me about the risks associated with the decision to do a 2nd fundo. The biggest problem is scar tissue from the first surgery as it can be extensive and make LAP surgery impossible. It is especially problematic if the scar tissue is heavy in the area around the esophagus & diaphram. If he can't do it LAP, he goes in through the chest - which is major, major surgery - and not to be taken lightly. He will not do the open surgery abdominally because he thinks the success rate is significantly reduced when the procedure is done this way.

    Because of scar tissue, the surgery can take 2 to 3 times longer than the first fundo. Plus, the surgeon is not working in virgin territory - the anatomy has been re-arranged, and, as a result, it can be difficult to tell where vital parts really lie when they are having to cut through a lot of scar tissue. This is a "high-rent" area and there is concern with accidently damaging the liver, speen, stomach, diaphram, esophagus, lungs, aorta, or vagas nerve when cutting the scar tissue. He always takes the first fundo completely down and redoes the entire procedure

    Finally, he made it clear that the fundo only fixes acid reflux. If your problems turn out to be due to something other than acid reflux, then the risks of the 2nd fundo obviously outweigh the benefits. This is one of the reasons he requires another round of testing before he agrees to do another fundo.

    I can definitely say that my recovery from the 2nd fundo has gone much more slowly than the 1st fundo - although this is not surprising since I had two fundos within 6 months.

    I think the most important things any of us can do when considering a 2nd fundo is #1 get a surgeon who is VERY experienced in re-dos and an expert in the field of acid reflux surgery, #2 get all the tests done even ones you have had before because everything changes after the first surgery, and #3 be patient (that's the hard one for me!) cause all of this takes time...lots of time.

    Am I glad I had the 2nd fundo?? Not sure yet...the jury is still out. Maybe I'll know in another 6 months. It takes courage to do a 2nd fundo, but sometimes that may be the only way to solve a very miserable reflux situation. Utimately, we have to trust the medical system, so doing our homework before proceeding with this major surgery is SO IMPORTANT!

    Good Luck to anyone needing to consider this surgery again. My prayers are with you.

    Joan

  • #2
    Thank you so much Joan! You're very brave. I wish I could see your doctor but money and other situations are keeping me in Texas at the moment.

    ~Heather

    Comment


    • #3
      Thank you for the very good post and the reality of the 2nd operation. The scar tissue becomes a real issue as you stated and the benefit to risk ratio had better be there to consider a re-do. I personally would like to have a take down but as you mentioned, the risks scare me, both in the fact of acquiring more complications and the real risk of a life threatening situation due to perforation etc.

      I have been told that reoperations whether fundo or whatever carry considerably more risk than the original as you mentioned.

      I wish you well in your recovery and hope your symptoms improve with time

      Steve

      Comment


      • #4
        Dr. Park's Post-op Instructions (Diet)

        I was asked by Buffy to provide the post-op instructions that were given to me by my surgeon, Dr. Adrian Park at the University of Maryland Medical Center. He is an expert in acid reflux surgery and has been a great source of detailed information for me.

        He was very emphatic that I adhere to the post-fundo diet he provided -- without exception or variation. The diet is designed to help proper healing of the esophagus and stomach. He believes that if you don’t follow the diet, you could prematurely stretch the area that was corrected by the surgery and cause some damage. (FYI - while still in the hospital following the procedure, I was not allowed to eat or drink anything except ice chips until I had an esophagram the morning after surgery to evaluate that fluids would properly empty into my stomach. Afterwards, I was given jello and apple juice.)

        Here are Dr. Park’s diet instructions.

        1. Your diet will progress slowly in stages, from just liquids to a normal diet. For most patients, it will take 8 weeks to return to a normal diet. (There are plenty of us on this board who have required significantly longer than 8 weeks!)

        2. You may lose weight. (He did not seem to be overly concerned with weight loss. I lost 30 lbs after my first fundo and 10 more after the second. I could afford it!) Take a liquid multi-vitamin supplement initially – you can switch to a chewable vitamin after week 2.

        3. You should eat small, frequent meals (6 - 8 a day). Start with 6 ounces of food per meal. If you do not have any problems, increase each meal by 1 ounce every 2 or 3 days.

        4. For 2 weeks, take only liquid (not solid) drugs as prescribed, then you may switch to chewable or crushed – where appropriate – until about 8 weeks.
        5. Eat only until you are full.

        6. Drink plenty of fluids with meals. Try switching bites of food with sips of fluids.

        7. Eat slowly and chew your food well.

        8. Sit upright when eating or drinking.

        9. Remain in an upright position for 20 minutes after eating. Do not recline.
        10. Adjust the temperature of the food for your comfort level.

        11. You may use spices as tolerated.

        12. Walking will improve digestion of food and help alleviate gas.

        13. Avoid alcohol, smoking, caffeine and bubbly drinks.

        14. Do not use a straw.

        15. Do not chew gum.

        16. Do not eat dry, hard foods (e.g., pretzels)

        17. The first week, you will remain on clear liquids with no caffeine and no bubbly drinks (e.g., soda/seltzer/carbonated water). Clear liquids include: water, apple or cranberry juice, Kool-Aid, broth, popsicles, Jell-O, decaffeinated tea and coffee (without cream). You can get extra calories and protein from high-protein clear liquid supplements such as Boost Breeze, Resource Fruit Beverage or NuBasics Juice Drink, available at a local drug store.

        18. Starting with week 2, you can have liquid and pureed foods with no chunks. Foods can be pureed in a blender. Examples: cream of wheat, cooked oatmeal (pureed), pureed pasta, pureed vegetables, vegetable juice, baby food vegetables, moist mashed potatoes, fruit juice without pulp or seeds, pureed fruit, smooth applesauce, baby food fruit, pureed meat, baby food meat, smooth puddings and custards, milk, milkshakes, ice cream, creamy style yogurt, pureed cottage cheese, sherbet, pureed soups, flavored fruit drinks, instant breakfast drinks, Ensure, Boost. (Not all patients will progress through the stages at the same rate. If discomfort increases, go back to the previous stage for a few days.)

        19. Weeks 3 -8 you should eat soft foods. Examples: hot cereals, cold cereals that soften with milk, crackers & biscuits that soften with liquids, cooked, finely chopped pasta, moist mashed potatoes, soft cooked finely chopped vegetables, soft canned fruit (no pineapple), soft peeled ripe fruit such as bananas, moist minced mean with gravies, soft cooked scrambled eggs, canned fresh or frozen fish without bones, smooth puddings and custards, milk, cream, buttermilk, chocolate milk, milkshakes, ice cream, frozen yogurt, whipped creamy custard style yogurt, cottage cheese, shredded soft cheeses, grated hard cheeses.

        20. Foods NOT allowed until after week 8: bread, rolls, muffins and bagels, granola, shredded wheat, pancakes, waffles, rice, raw vegetables, corn, coleslaw, salads, baked potato with skin, fruits with seeds, nuts, peanut butter, raisins, dates, hard fruit with skin, dried or candied fruit, un-chopped meat, dry meat, fish with bones, yogurt that contains fruit or nuts, un-grated hard cheeses, coconut, popcorn, pickles, carbonated drinks, caffeinated drinks, chips, alcohol.

        Comment


        • #5
          Dr. Park's Post-op Instructions (Other)

          Other post-op instructions from Dr. Park included:

          1. Slowly return to a normal level of activity over 4 – 5 days while avoiding activities that cause uncomfortable pain. Walking is very good for the healing process. Stairs are fine.

          2. NO HEAVY LIFTING greater than 10 - 15 lbs for 8 weeks.

          3. Avoid driving for at least 48 hours and until you are no longer taking narcotic pain medication.

          4. Shoulder pain is not uncommon for the first 48 hours and is usually relieved by lying down on the affected side.

          5. Most people can return to a desk-type job within two weeks of surgery. If your job requires strenuous activity, you should return on restricted, light duty.

          6. Your incisions have internal stitches that will dissolve and are covered with steri-strips.

          7. You may remove any gauze dressings and shower 2 days after your surgery, allowing the soap and water to gently pour over the sites. After 5 – 7 days, you can remove the steri-strips.

          8. Temporary tenderness and bruising at the incisions are not unusual.

          9. Constipation is not unusual after surgery. This should improve once you stop your narcotic pain control, and eventually increase your fiber in your diet.

          10. A mild stool softener such as over-the-counter Colace, should help.

          11. Drink plenty of liquids.

          When I asked him about how long the 2nd fundo would last, he said that's where it really becomes a team effort. He said, "I have done what I can do to give you a good wrap. Now you must take care of that wrap." He believes you must permanently alter your eating habits to get the most longevity from the wrap - multiple small meals a day, eaten slowly, small bites, well-chewed.

          Hope this information is beneficial to those preparing for the surgery I wish you the best!

          Joan

          Comment


          • #6
            Thanks for the great information. I wish more surgeon's were as thorough with diet instructions as yours has been. There would probably be a lot less discomfort and possibly complications.

            Thanks for sharing as it may help prospective fundo patients have a successful recovery.

            Comment


            • #7
              fundo

              I went to john hopkins gi doctors for 6 months,they would not do any test,I was told spastic colon.Not to eat grapes,beans,and learn to live with it...I had one of the worst cases of gerd ever posted on this board,I wanted to die,thats just how bad the pain was....I read this board for 2 yrs back in 2000-2002.....This gave me hope....Had the surgery done at Mercy in Baltimore.Great Doctor,great hospital,had all test done....dont remember them but my test scores were real bad reflux....had fundo 6 weeks after test..its been 5 yrs feeling great no reflex,This is not the answer for everyone,but well worth it,if nothing else works...

              Comment


              • #8
                birdybird,
                I recently posed your comments to a GI doctor, and he had this to say:

                "In competent hands, no. Nissen revisions are relatively straightforward.
                I agree that completely taking the Nissen down is correct. Those
                operations can indeed take longer due to adhesions (scar tissue) from
                previous operations, and then having to identify the cause of the
                failure and correct that, but not being able to deal with those problems
                and then open the patient is a clear sign of a surgeon whose
                laparoscopic skills are limited. Likewise, going through the chest is
                almost a laughable concept these days. If the Nissen couldn't be revised
                (take down the wrap without damaging the stomach), converting it to a
                roux-en-Y bypass is current state of the art

                Pick your surgeon carefully. Make sure you clearly understand and have
                confidence in his/her skills at laparoscopic revisional surgery. "

                Comment


                • #9
                  I agree with the statements made by the G.I. doc but I am a little confused at the last of the statement. It said if the stomach couldn't be taken down w/o injury then converting it to a Roux-en-Y which is currently state of the art. These are two different operations neither help the other. The Nissen obviously reduces or eliminates reflux while the bypass is for weight reduction without reflux control. If the wrap can't be taken down, why go to a bypass?

                  I'm just trying to see the benefit,
                  Thanks

                  Comment


                  • #10
                    Originally posted by CTD View Post
                    I agree with the statements made by the G.I. doc but I am a little confused at the last of the statement. It said if the stomach couldn't be taken down w/o injury then converting it to a Roux-en-Y which is currently state of the art. These are two different operations neither help the other. The Nissen obviously reduces or eliminates reflux while the bypass is for weight reduction without reflux control. If the wrap can't be taken down, why go to a bypass?

                    I'm just trying to see the benefit,
                    Thanks
                    Doc says, "If the wrap can't be taken down because the scar tissue is too dense,
                    better to just resect that part of the stomach and do the roux-en-Y,
                    than risk leaving a stomach segment that could perforate and leak.
                    Roux-en-Y gastric bypass is actually better at controlling reflux than a
                    Nissen, and has no possibility of failure. With the RNY, there's nothing
                    to reflux...the defective LES is completely taken out of the equation. "

                    Comment


                    • #11
                      Nick

                      Originally posted by TexasNick View Post
                      Doc says, "If the wrap can't be taken down because the scar tissue is too dense,
                      better to just resect that part of the stomach and do the roux-en-Y,
                      than risk leaving a stomach segment that could perforate and leak.Roux-en-Y gastric bypass is actually better at controlling reflux than a
                      Nissen, and has no possibility of failure. With the RNY, there's nothing
                      to reflux...the defective LES is completely taken out of the equation. "
                      Hi Nick If the roux-en -y is better at controlling reflux than a fundo as your GI says , then ask him why ever do a fundo ?

                      I've read it has a very high level of side effects , such as dumping , bezoars , nausea and vomiting .

                      Also..... a vagotomy is usually done with a roux-en-y to control the acid . You could get dangerous bleeding ulcers and not even know it.

                      WE've had several on the board with 2 failed fundos have a roux-en -y with vagotomy . Also along with that a hemigastrectomy and a gastrojejunostomy , It's kind of more complicated than your doctor might imply .

                      Comment


                      • #12
                        Doc says,

                        "Little changes in the secretory activity of the bypassed stomach.
                        Parasympathetic activity is basically intact, and all of those enzymes
                        and other stuff are still available for digestion. Bile reflux across
                        the pylorus is still possible, although as I've mentioned before, I
                        doubt this an issue in an autonomically intact stomach remnant.

                        Ulcer problems can be difficultand we don't do RNY on patient's with
                        known peptic ulcer disease. Indeed the distal stomach and duodenum are
                        no longer endoscopically accessible, and in rare circumstances that can
                        be a diagnostic and/or therapeutic problem. We always biopsy for H
                        pylori as part of the preop workup and make sure we can eradicate it if
                        present.

                        There are side effects of RNY, just as there are for Nissen. Dumping
                        syndrome is one, although relatively uncommon. New eating habits are
                        required. Vitamin absorption can be an issue. RNY is a big operation, no
                        insurance company I'm aware of will pay for it for GERD alone. The
                        University of Minnesota has a grant to do a study on LRNY as primary
                        operation for GERD patients with BMI's between 30-35 because of the
                        well-known very high failure rate of Nissen in obese patients. Our own
                        experience has been with re-operation on patients with failed Nissens in
                        whom fundoplication revision wasn't possible. It's been very successful
                        in that regard and I've yet to see a patient who was dissatisfied with
                        that (although, admittedly we're only talking about 11 patients so far). "

                        Comment


                        • #13
                          Nick

                          Thanks Texas Nick Your GI is very accomodating as far as answering questions , which is very nice.

                          Yes i've read it's been pretty successful for people with a high BMI , but the internet is crawling with people who are very disatisfied with the side effects .

                          I do agree it is a much better option for people with multiple failed fundoplications .... they used to treat these people with esophageal resection.... some physicians still do.

                          Well as i mentioned we have two people on this board who have had the roux en y after 2 failed fundos . . Poster "Jenn " from Texas is one . She hasn't posted in a long time . Hopefully that means she is feeling much better . It will be interesting to see how these people do

                          Comment


                          • #14
                            Originally posted by Tricia View Post
                            but the internet is crawling with people who are very disatisfied with the side effects .
                            No problem Tricia. I'll ask the GI doc what he thinks about yoru latest comment. On the other hand...of course the internet will be crawling from people disatisfied with their side effects....I dont' think the happy people will post.

                            I'll let you know what he says.

                            Comment


                            • #15
                              Nick

                              Hi Nick Probably no need to bother, I'm sure thats what your GI will say anyway , happy people don't post. Thank you Nick

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