Nissen after TIF

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PPI-LESS
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   Posted 12/29/2011 4:54 AM (GMT -6)   
In TIF's literature online, it is claimed that one can still get Nissen done after an (unsuccessful) TIF. However, I am wondering that ... if for TIF they have to pull down the stomach tissue around LES, then would they still have enough on the fundus end to do the Nissen wrap?

I do see some mention of having to do Nissens after TIF in the clinical studies - but I wonder if Nissen's odds of being successful are still the same when doing them on top of the TIFs.

Post Edited (PPI-LESS) : 12/29/2011 5:59:24 AM (GMT-7)


bcfromfl
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   Posted 12/29/2011 10:10 AM (GMT -6)   
Hi PPI-LESS --

I'm not sure I'm following you when you say, "...if for TIF they have to pull down the stomach tissue around LES..." Yes, the fundus is fastened against the LES, but it's easier to think of it as the esophagus/LES being stretched/pulled into the stomach cavity first. The fundus probably rests at the same position following the procedure as before.

If what you mean is that the ability of the fundus to be lifted around the esophagus is lessened as a result of the TIF fasteners, this is probably somewhat true. In this case, the surgeon would grab the fundus a little further down, below the fasteners, and lift a bit more fundus tissue a bit higher above the TIF surgical site.

Actually, this might result in a slightly better fundoplication, because there is more tissue gathered around the lower esophagus than with either procedure alone. The previous stretching from the TIF has already healed, and with the extra 1-2cm above the TIF, perhaps makes a larger reflux barrier. Just my opinion, though...

=Bruce

opnwhl4
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   Posted 12/29/2011 2:07 PM (GMT -6)   
PPI-LESS-

They get the fundus for the wrap by freeing it from the spleen. So I think it is very possible to have a good nissen after the TIF. My first nissen was done wrong and the surgeon didn't release enough from the spleen to make a tension free wrap. This was corrected during my first redo.

Take care,
Bill
opnwhl4
Moderator: GERD/Heartburn
Nissen 6/06 and 5/09
#3 on 8/24/11

PPI-LESS
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Total Posts : 375
   Posted 1/3/2012 4:40 PM (GMT -6)   
Bruce -
Since your TIF has not given you the relief you were looking for, are you considering Nissen at all?

I am still trying to make up my mind if I should:
1. Try TIF first
OR
2. Go with Nissen.

In the first case, there is less risk of side effects but there is a risk that it may not work or the durability will be limited to a handful of years.

In the second case, if it works out well - then one can be symptom free for 10+ years and may be even more!

I am going to go talk to various surgeons before making up my mind .. but I know I will have to choose one of the above fairly soon. I just can not go on with the symptoms and let my life pass me by (in pain/discomfort).

Ollie7
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Date Joined Nov 2011
Total Posts : 14
   Posted 1/3/2012 5:36 PM (GMT -6)   
I just returned from a second surgeon at major University and he's not for or against at this point. Thinks there may be a good place for it as a "Silver" standard some day. I would be more inclined to try it if it was covered by my insurance - which it is not, so if I am going to do surgery, I want to make sure it is covered as much as possible.

aeshleyrose
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Date Joined Jul 2011
Total Posts : 655
   Posted 1/4/2012 8:22 AM (GMT -6)   
Bruce, because you're so knowledgeable I've been really looking forward to your answer about whether or not you're considering the NIssen. I'm also in the GERD chat room if you're interested.

bcfromfl
Regular Member


Date Joined Nov 2011
Total Posts : 384
   Posted 1/4/2012 9:23 AM (GMT -6)   
I had my first visit yesterday with a new GI at the Mayo Clinic in Jacksonville.  500-mile round trip!  Had all my charts with me, plus my prepared notes and history.  I've never had a doctor spend an hour and fiteen minutes with me, ask lots of questions, take notes, etc.!  In spite of all my evidence, he, however, remains very skeptical about my symptoms, and wants to proceed slowly.  (I'm finding that GIs HATE LPR symptoms!!  Nearly impossible to diagnose correctly, or treat.)  On one hand, I appreciate his caution, but on the other, I'm very frustrated that I'm still not making any progress in getting this resolved, or moving in one direction or another.  I want to get this over with!  He wants me to get a barium swallow and impedence test, and return with those to consult with the GI surgeon.
 
He did concede to me, that those reflux patients who exhibit "atypical" symptoms are at a much lower resolution rate following surgery than those with typical symptoms.  I knew this, but it's sobering to hear from him.  On almost a lark, he wrote me a prescription for nortryptilene -- a tricyclic.  It's normally an anti-depressant at higher dosages, but they've found that at low dosages, it can serve as a "de-sensitizer" of the esophagus for those patients who are predisposed to being abnormally sensitive to the irritation of reflux.  (In his opinion, nortriptylene is superior to amitriptyline.)  He suggested that since my reflux is now in the "normal" range (per my latest Bravo study), that perhaps this might help...but at least "worth a shot" since I'm pretty much out of options.  Now *I'm* the one who's skeptical, but I'll experiment with this and see if I notice any difference.
 
He asked what persuaded me to go with the TIF instead of the Nissen, and I explained my reasons.  Mostly that the TIF was less-invasive, offered good hope, and wasn't as radical as the Nissen, as well as the possible complications that can arise from the Nissen...and basically having my guts rearranged!  My reasons resonated with him, and he's glad that I'm well-informed and resistant to the idea of major surgery...and not impulsive.
 
I'm at the Mayo Clinic because both my local GI and the TIF surgeon have sent me there, and both of them told me that the Nissen is my only option at this point.  Not a good prognosis, but I'm trying to move forward one step at a time...albeit S  -  L  -  O  -  W  -  L  -  Y!!!!!  If someone put the surgical order in front of me right now, I couldn't sign on the dotted line for a Nissen.  I'm trying to prepare myself for that, and perhaps if I'm faced with an ultimatum, maybe the choice will be more straightforward.
 
I asked him if there are any special considerations or limitations about doing a Nissen on top of a TIF.  He said he's not a surgeon, and will defer that opinion to the Mayo surgeon when I consult with him after the new tests.
 
I really appreciate the fact that this resource, the HealingWell GERD forum, is here, and offers the community support it does.  It helps me to read through posts, respond here and there, and in general think my way through this mess!
 
PPI-LESS...I know EXACTLY where you're at.  My quality of life these past three years has been in the toilet.  Yes, we can still "function" day in and day out, but the misery and limitations makes life a chore, and, for the most part, joyless...
 
-Bruce

PPI-LESS
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Date Joined Apr 2011
Total Posts : 375
   Posted 1/4/2012 1:42 PM (GMT -6)   
Bruce - Good luck at the Mayo Clinic! Hoping you can find something that works ..

I am still so confused about whether I have GERD or LPR ... it seems like I have both ....

When all this started in Feb/March 2011, I had mostly LPR symptoms: thick mucous in the throat, throat ache, swollen vocal cords, pooled acid in the throat etc. I had almost no heartburn symptoms. However, my symptoms have changed so much in the last several months. Now, my throat symptoms are 80% better (ENT scoped the throat 2 months back and declared that the swelling had gone down considerably). However, now I get heartburn, chest aches often - which immediately follow with sour taste in the mouth and throat symptoms. However, these throat symptoms are not as bad as what they used to be ... and if there is no heartburn, then I don't notice any sour taste in the mouth ...

So, based on these symptoms, what I am hoping is that if the surgery can get rid of the heartburn and clamp down the acid, then likely my symptoms in the mouth should reduce / go away and the throat should also heal up ... I understand that some acid can still come up .. but am hoping that it won't be enough to cause the symptoms ...

I've not had cough/asthma like symptoms - yet.

I guess when someone has only-LPR symptoms, then the surgery may not solve the problem - however, when someone has GERD and LPR (mostly-GERD and some throat/mouth symptoms) - then I am assuming that the chances that the surgery can fix things are better .. I can see why Nissen has a better shot at fixing this than TIF - but if Nissen can be done on top of TIF, I feel inclined to go with TIF to start with ....

... and BTW, if I force myself to stay on the PPIs for a few days the symptoms do tend to improve - but then I start to get side effects and I have to get off of them .. I can't last more than 2-3 days on the PPIs .. as the acid reducing effect builds up - so do the side effects ...

aeshleyrose
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Date Joined Jul 2011
Total Posts : 655
   Posted 1/4/2012 2:00 PM (GMT -6)   
Hey PPI-Less,

That's pretty much where I am, too. I need further testing (pH monitoring, namely) but the heartburn/regurgitation/discomfort is becoming pretty unbearable and I can't see any other way of dealing with it. I mean, if the whole problem is that the acid won't stay put, I can't see how the Nissen WOULDN'T help us (except in cases like Denise has said, if someone is super sensitive to the reflux).

Best of luck to you! Please keep us updated on your progress. Have you seen a surgeon yet? Has a doc (GP or GI) recommended the Nissen to you?

Ashley

aeshleyrose
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Date Joined Jul 2011
Total Posts : 655
   Posted 1/4/2012 2:04 PM (GMT -6)   
Hey Bruce, sorry things aren't going fast for you. I feel you there, for sure.

Let us know how the tricyclics work for you. I've heard of them being prescribed for esophageal sensitivity but haven't heard back about whether or not they work.

Take care,
Ashley

PPI-LESS
Regular Member


Date Joined Apr 2011
Total Posts : 375
   Posted 1/4/2012 2:17 PM (GMT -6)   
Thanks Ashley,

I got pH/Impedance test done recently and it does indicate reflux (I still need to get the final test result report with the demeester scores etc. from the GI).

The last I spoke with my GI - he gave me two options (given - that I can not take the meds):
- Surgery (however Nissen only - he does not want me to do TIF)
- Wait and see how / if the symptoms evolve in another 6 months to a year.

I don't think I can last out 6-12 months - given my quality of life.

I see my GI again in the next 10 days or so and then will make an appointment with one of the 2 surgeons he recommends. Meanwhile, I am also seeing 2 other surgeons who do TIFs (one on the 17th and another one on the 25th).

I will report on how it goes with these appointments .. but I am hoping I can take a decision in the next 6-8 weeks.

Best of luck to you too!

bcfromfl
Regular Member


Date Joined Nov 2011
Total Posts : 384
   Posted 1/10/2012 9:40 PM (GMT -6)   
I wanted to add to this thread to set the record straight. What I said above about doing a Nissen on top of a TIF is not correct. I just met with a surgeon today, and, in the case of a Nissen after a TIF, the TIF is disassembled so the doctor can "start from scratch." He didn't seem to indicate that it was a big deal, and I asked, "Isn't it difficult to locate the fasteners after tissue has grown around them?" He said no.

-Bruce

Glass12
Regular Member


Date Joined Nov 2011
Total Posts : 44
   Posted 1/11/2012 2:27 PM (GMT -6)   
Bruce
Please let me know how you make out. I had tif done 10/31/11 and now out of the blue i have pressure in throat and its sore.Going to ent and having endo done friday. i think the worst part of the tif is that dont tell you it can make it worse. i had it done thinking it either worked or it didnt. Now I think I might have to have nissen done. This sucks . If I knew then that it could have been worse I would have waited a little longer. Again keep in touch and good luck. I think Im going down the same path as you
Steve

PPI-LESS
Regular Member


Date Joined Apr 2011
Total Posts : 375
   Posted 1/11/2012 2:37 PM (GMT -6)   
Steve,

When you say TIF has made it worse .. do you mean to say that because of TIF, there is more acid coming up in your throat that is causing the pressure and the sore throat? I've heard people here say that TIF didn't help them with the symptoms - but seems like you are the first one who is saying that TIF is actually causing more acid reflux to occur than before the procedure.

Hope the tests can help you figure out the root cause of your problems.

bcfromfl
Regular Member


Date Joined Nov 2011
Total Posts : 384
   Posted 1/11/2012 2:38 PM (GMT -6)   
Hi Steve --

I'm really struggling with continuing the motivation to forge ahead with this...don't know what I'm going to do, especially with such an apparently low success rate for "respiratory reflux". Best wishes with your test on Friday.

I also should add that the nortriptylene therapy was a failure, too. I made it two days on the extremely low dose pills, but had to stop because of dizziness and impairment.

-Bruce

opnwhl4
Forum Moderator


Date Joined Dec 2008
Total Posts : 4841
   Posted 1/11/2012 8:14 PM (GMT -6)   
Bruce-

I am surprised by your doctor saying that the nissen for respiratory reflux is low odds. Everyone I have talked too that had this and went with the nissen is doing great. I know 4 other people who are not on this forum who have done this.

Take care,
Bill
opnwhl4
Moderator: GERD/Heartburn
Nissen 6/06 and 5/09
#3 on 8/24/11

bcfromfl
Regular Member


Date Joined Nov 2011
Total Posts : 384
   Posted 1/11/2012 9:38 PM (GMT -6)   
Hi Bill --

I guess I didn't clarify in this thread. It's not simply respiratory reflux and the Nissen, it's those patients with respiratory reflux, plus either are intolerant of, or don't respond well, to PPIs. The reasoning is this: it's simply impossible to achieve 0% reflux with surgery or meds. Those patients who respond well to PPIs have demonstrated enough resilience to the remaining reflux to no longer be symptomatic. When those patients have surgery, they achieve approximately the same, or a little better results in terms of reflux suppression...hence, successful procedure.

A small minority of patients are more sensitive to small amounts of reflux. For those patients who don't achieve good results with PPIs, they aren't going to see much better suppression with surgery. This is where I'm at, unfortunately. As a result of my TIF procedure, I'm already pretty close to what can be achieved with a Nissen, but the doctors want confirmation of my current reflux status, as well as an indication of how high it's traveling, so I have to schedule an impedence test. Then they can advise me, yay or nay, about what continued surgical intervention might/might not offer.

-Bruce

PPI-LESS
Regular Member


Date Joined Apr 2011
Total Posts : 375
   Posted 1/11/2012 10:40 PM (GMT -6)   
Hi Bruce .. I see your reasoning on the 'dont respond to the PPIs part' - but not on the 'intolerant of the PPIs part' ..

So, its not that the PPIs don't work for those who are intolerant .. but they cause side effects ...

For example .. it seems that you were able to manage your reflux with the H2 blockers for close to a year or more ... so, in theory this acid suppression did help you ... so it follows then that the surgery should've helped you too ... no?

bcfromfl
Regular Member


Date Joined Nov 2011
Total Posts : 384
   Posted 1/11/2012 11:02 PM (GMT -6)   
Well...this is where I'm getting into the unknown. I did have success with the H2 blockers early on, but I don't believe my reflux was at the stage of severity it is now. It is true that Nexium helps my symptoms, so, in that respect it seems to indicate that surgery should work. But when the GI and the surgeon looked at my Bravo results, they both shook their heads and said that I have really, really low reflux now, and that a Nissen shouldn't improve upon that much.

Now, I did point out the fact that I still had ~30 or so episodes during the 48 hours. Even though they might be of short duration, the surgeon still agreed that that number could produce the symptoms I have. However, he also said it's entirely true that I could have great results from the Nissen, that would disappear in 4-5 months, and then I'd be left with nothing to show for it, plus all the additional caveats from the wrap itself.

The kicker in all this is the botched Bravo I had last time. I can't remember if I mentioned this previously. The nursing staff gave me a Reglan tablet ahead of time as a matter of protocol for EGDs, to prevent nausea. They didn't realize the side-effect of tightening the LES, and this corrupted at least the first 24 hours of the study. This is one of the reasons the Mayo doctors want an impedence test. It's entirely possible that my reflux is worse than the Bravo indicated, and, that the Nissen could offer an improvement.

I really, really hate all this! All the time, and money, and brainpower I'm devoting to this, that could go in more productive directions...

-Bruce

opnwhl4
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Date Joined Dec 2008
Total Posts : 4841
   Posted 1/12/2012 8:35 AM (GMT -6)   
Bruce-

Yes, that makes more sense. Thanks for clearing that up for me. I forgot about them giving you the Reglan before the bravo. That wasn't a good decision on their part.
The impedence test should should show what is really going on. The tests are fun, but are a necessary evil.

Take care,
Bill
opnwhl4
Moderator: GERD/Heartburn
Nissen 6/06 and 5/09
#3 on 8/24/11

bcfromfl
Regular Member


Date Joined Nov 2011
Total Posts : 384
   Posted 1/12/2012 8:50 AM (GMT -6)   
After thinking about this some more last night, I think I know why the doctors include the patients who are intolerant of PPIs in their prognosis. Those patients who have a high sensitivity to reflux sometimes find it still necessary to continue PPIs after surgery to try to get closer to that magic "0%" number. The respiratory reflux patients, of course, wouldn't be able to take the PPIs because of the side-effects, hence, the surgery fails to resolve symptoms in this subcategory.

Maybe?

-Bruce

bcfromfl
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Date Joined Nov 2011
Total Posts : 384
   Posted 1/12/2012 1:05 PM (GMT -6)   
I found this discussion of GERD vs. LPR at the following link: http://www.entandallergy.com/vas/services/reflux.php  I'm copying some of the article below...what I find interesting are the statistics.
 
-Bruce
 
Symptoms
 
 GERD (GastroEsophageal Reflux Disease) symptoms are typically different than LPR (LaryngoPharyngeal Reflux) symptoms, but patients can have symptoms generally associated with either GERD or LPR.
 
Classic GERD symptoms are: Heartburn; regurgitation.
 
LPR Symptoms are: Hoarseness; frequent throat clearing; increased phlegm; post-nasal drip; chronic cough; difficulty swallowing (dysphagia); lump-like sensation in throat; choking sensation.
 
Laryngo-Pharyngeal Reflux (LPR) is DIFFERENT from Gastro-Esophageal Reflux Disease (GERD) . The "CLASSIC" Symptoms of GERD in a typical ESOPHAGITIS patient are HEARTBURN - 83%, COUGH - 47%, DYSPHAGIA - 40%, REGURGITATION - 23% (1). On the contrary, the typical symptoms of LPR in the typical ENT patient are HOARSENESS - 71%, CHRONIC COUGH - 51%, DYSPHAGIA - 51% GLOBUS - 47%, THROAT CLEARING - 42%, HEARTBURN and/or REGURGITATION - 10%-33% (2, 3, 4).
 
The reflux pattern in the typical GERD patient is a supine, nocturnal reflux (patient refluxing while lying flat at night) while the LPR patient generally refluxes while upright during the day (2, 3).
 
Esophageal function in the GERD patient generally demonstrates esophageal dysmotility with significantly prolonged esophageal acid clearance times and Lower Esophageal Sphincter dysfunction. In contrast, the LPR patient has good esophageal function with near normal esophageal acid clearance. Generally, LPR patients have Upper Esophageal Sphincter dysfunction (5, 6). In addition, the larynx is far more susceptible to acid injury than esophagus because in the larynx there are no acid clearing mechanisms (peristalsis; salivary bicarbonate) and the laryngeal tissues are thin, fragile and poorly adapted to protect against reflux. One normally refluxes about 50 times a day from the stomach into the esophagus. If as few as 2 of those normal reflux events contact the laryngeal tissues, it is abnormal, and changes in the laryngeal tissues can result (3, 7). Therefore, it is LARYNGEAL EDEMA, or swelling, not ERYTHEMA, or redness, that is the clinical hallmark of LPR (4).

Glass12
Regular Member


Date Joined Nov 2011
Total Posts : 44
   Posted 1/12/2012 4:49 PM (GMT -6)   
To answer question about the tif surgery what im saying is before the surgery i didnt have trouble with my throat. I feel that the surgery made me worse because in the past I could go a week without any meds but all of a sudden 9 weeks later im hurting in the throat. I have to say im scared to death that i made the wrong decision and should have waited to do something else. Ive posted asking if anyone has had a nissen after tif and it looks like bruce might be going down that road.I saw ent today and as i thought acid on vocal cords is why i feel a lump. I really wonder if a nissen would be the answer because now im worried the surgeon messed up the les muscle and there is no return. God i wish i could find an answer as bruce has stated its a lot of time and brainpower it's crap you put trust in doctors and it seems that if it doesn't work oh well move on to someone else. Need to vent.

bcfromfl
Regular Member


Date Joined Nov 2011
Total Posts : 384
   Posted 1/25/2012 6:02 PM (GMT -6)   
Just returned from another trip to the Mayo Clinic in Jacksonville, to get the impedence pH test.  I know many of you have had this test, but HOLY COW...it is NO JOKE!!!!  I had a really hard time with it, plus I was staying by myself in a motel room off campus for the duration.  I'm kind of a private person normally, and it was extremely humbling to have everyone staring! :(  I do understand that it has a couple of big advantages over the Bravo pH study, and this is why the doctors recommended it. 
 
I think because I'm still having throat issues and borderline globus, was why it was so uncomfortable.  Hardly slept.
 
I packed food with me so I wouldn't have to leave the room.  The technician/nurse told me that it's only important to have readings of 3-4 hours following two meals, and the readings while sleeping.  So, it was actually removed after about 21 hours or so.  They'll call in a day or two with the results.
 
Recently, tiflady posted in the thread, "Hi I'm new, just had TIF..." that she had the Toupet on top of a TIF.  So, apparently there is a difference of opinion between surgeons whether this can/can't should/shouldn't be done.  IMO, I think it would result in a superior barrier, but, what do I know?  :)
 
-Bruce

maximus808
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Date Joined Sep 2011
Total Posts : 620
   Posted 1/25/2012 7:49 PM (GMT -6)   
Is the impedance test to measure the refluxes in esophagus and larynx?
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