TIFF to tighten a Nissen?

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Dave234
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Date Joined Oct 2011
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   Posted 7/3/2012 9:51 AM (GMT -6)   
Has anyone heard of this?

stkitt
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   Posted 7/3/2012 12:04 PM (GMT -6)   
I understood the Dr. would have to actually go in and re-do the surgery. If your referring to the TIF EsophyX Incisionless Surgery to repair your too loose wrap, I do not know the answer but I am sure someone will.
 
Kindly,
Kitt
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bowecho
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Total Posts : 146
   Posted 7/3/2012 12:09 PM (GMT -6)   
I think if a Nissen is determined to be too loose it can be tightened. I think a member here has had that done, I forget their username. I don't think they'd have to do an entirely different procedure such a TIF. I'm not sure if you can have that done after the area of your body has been modified through Nissen, but I could be wrong.
Learn lots. Don't judge. Laugh for no reason. Be nice. Seek happiness.

Dave234
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Date Joined Oct 2011
Total Posts : 338
   Posted 7/6/2012 3:15 PM (GMT -6)   
Anyone?

Cmac3721
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Date Joined Dec 2011
Total Posts : 36
   Posted 7/6/2012 6:29 PM (GMT -6)   
My suregon suggested this also???? Can it work does anybody know please!!!

Dave234
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Date Joined Oct 2011
Total Posts : 338
   Posted 7/11/2012 10:00 AM (GMT -6)   
Where is your surgeon, Cmac?

Muaz
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Date Joined Jul 2012
Total Posts : 1
   Posted 7/12/2012 2:18 AM (GMT -6)   
best fundoplication doctors are in India. Dr. Palanivelu, Gems hospital, Koipatore. India. He can do anything laproscopically

Dave234
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Date Joined Oct 2011
Total Posts : 338
   Posted 7/16/2012 8:03 AM (GMT -6)   
Has no one heard of this?

Jessicaudd
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Date Joined Oct 2012
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   Posted 10/12/2012 6:16 PM (GMT -6)   
I want to bump this, because I am currently doing some research on it and would like to see if anyone has first hand experience :)

babygirl10150
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Date Joined Jul 2006
Total Posts : 639
   Posted 10/14/2012 12:47 PM (GMT -6)   
Yes, my current GI has suggested this. My nissens were all tightened lap using the same incisions. This GI brought up the TIF to tighten it again because they don't use any incisions. He said the H clamps (?) might hold better that the sutures. But because my barium swallow showed no reflux, even though I can feel it, he wants to wait until I see my other dr.
Michelle

~Diagnosed with POTS 10/11~
~Nissen redo #3 coming soon~
~Nissen redo again 12/13/10~
~Nissen redo 05/10/10~
~Nissen 12/14/09~
~Colostomy 07/30/06~

bcfromfl
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Date Joined Nov 2011
Total Posts : 417
   Posted 10/14/2012 3:57 PM (GMT -6)   
I would caution anyone from pursuing this, or investing in a surgeon with this recommendation.  I would definitely get a second opinion!  While it is possible to do a Nissen on top of a TIF, as a couple of members of this messageboard have had done, IMO, a TIF on top of a Nissen defies the new architecture of the fundus/esophagus.
 
In a TIF, the esophagus is essentially pulled/stretched into the fundus, and the fundus lifted from the inside, up and around the LES...where it is fastened with plastic H fasteners.  A Nissen, however, stretches and lifts the fundus around the esophagus from the outside, somewhat from the "back/left," wraps it around the esophagus, and stitches both sides of the fundus together and through the esophageal wall on the "front/right."
 
While it might be possible to do a TIF-like attachment post-Nissen through the esophageal wall into the fundus on the "back/left," there really wouldn't be much advantage to doing this.  Yes, it might help support the entire fundoplication, but I'm not sure how much could be expected from a few staples.  After a few months, there is already natural attachment going on all around where tissues are pressed together anyway.
 
If a surgeon is suggesting this as a means to somehow "improve" the function of the Nissen, and reduce reflux, this is not possible.  The LES is already benefiting from the peristalsis of the fundus by virtue of the Nissen.  If the suggestion is to "tighten" the Nissen, this is also not possible with a TIF.  The tightness of a Nissen is determined by the exterior, lateral stretching of the wrap, not how tightly the fundus is secured against the esophagus...which is all that the TIF would accomplish.
 
The "front/right" part of the Nissen would be totally inacessible to an EsophyX device.  This is the weakest part of a laparoscopic fundoplication, and where such support really would be advantageous were it possible.  Understanding how the ExophyX device works, one can see that it is not possible to use this device to perform a conventional TIF following a Nissen.
 
-Bruce

Dave234
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Date Joined Oct 2011
Total Posts : 338
   Posted 10/15/2012 11:46 AM (GMT -6)   
Thank you for the information. A little background on my surgeon, to put it in perspective. He has done over 1,000 nissens, and has fixed other doctors' mistakes. He has never had to fix his own. He teaches other doctors how to do the nissen. He was also recommended to me by my gastroenterologist.

Are you sure that a TIF can't serve to "tighten" an existing nissen?

bcfromfl
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Date Joined Nov 2011
Total Posts : 417
   Posted 10/15/2012 5:31 PM (GMT -6)   
I don't know how much you understand about these two procedures, and I apologize if what I write below is redundant.
 
The only way you're going to get a good answer to your question, is to define the word, "tighten."  Tighten the fastening of the fundus against the esophageal wall?  (Perhaps to make the Nissen more secure against slippage?)  Tighten the action of the Nissen?  (Presumably because it's not stopping enough reflux?)  I tried to address both concerns in my post above, as its use in this respect is somewhat ambiguous, and impossible to address specifically.
 
If your surgeon has never had to fix his own procedures, why is this on the table?
 
Also, and I'm presuming this is for your own case, have you had a post-op pH test?  (This is also presuming that the Nissen is not stopping the reflux that it should, and therefore needs "tightening.")  The theoretical limit of a Nissen is 2.0% pH<4.0.  The lap Nissen does not stop all reflux, even when it's performing "perfectly."  Any attempt to make it perform better than this 2.0% number is misguided.
 
I understand that it's difficult to visualize what's going on with a lap Nissen or a TIF from a textual description.  If you can't approximate it using both hands in front of you to help visualize, try finding images or video.  Because of the way the Nissen is wrapped around the esophagus, it makes most of the circumference of the wrap inaccessible to the EsophyX device, especially if natural post-surgical attachment has taken place.  It's possible that the doctor could've used the term, TIF, in an off-handed way, meaning that his intention was to use the EsophyX device (or even another type of surgical stapler) in an UNCONVENTIONAL manner to make attachments.  It would not be correct to call this a TIF procedure, but simply a means to use the EsophyX device as a stapler.
 
As I pointed out in my post above, the "tightness" of the lap Nissen is determined by the wrap.  No amount of stapling through the esophageal wall, even if it were possible 360 degrees, would improve upon this.  Even if it were possible, all it would accomplish is securing the fundus more tightly against the esophagus...it would do nothing to improve the peristaltic waves of the fundus, which is what presses the LES closed.
 
It's these same peristaltic waves that cause reflux in the first place, when the LES is weakened.  Therefore, using the fundus around the LES in a lap Nissen, it replaces the LES function somewhat, and also insures that the initial peristaltic waves clamp the LES shut first before the waves move through the stomach.
 
The stand-alone TIF is inferior to the lap Nissen, because the TIF only lifts and secures the fundus against the esophagus, and the surgical site only covers perhaps one centimeter of free-hanging esophageal tissue into the stomach, plus another 1.5 cm. of stapling above it.  (Also, because of the limitations of the device to be able to rotate, it can't complete a full 360-degree procedure.)  The Nissen perhaps doubles the size of this surgical site.  The additional benefit of the Nissen is the pressure of the wrap around and against the LES...but again, this pressure is due to the tension of the lap laterally around the esophageal wall and secured with the four sutures.  The exact tension is determined by the surgeon through the use of a bougie inserted down the esophagus as he is suturing. 
 
This is pure conjecture on my part, but if the surgeon inserted a surgical stapler through one of the abdominal entry ports to gain access to the "front/right" section of the wrap where the sutures are located, grasped the two ends of the fundus wrapped around the esophagus and pinched them more closely together -- then stapled them fundus to fundus -- this would make a tighter wrap.  This has no resemblance whatsoever to a TIF procedure (as the TIF is done transorally), but it could use H-fasteners and a stapling action similar to a TIF.  This would not work on a Toupet, because the ends of the fundus are intentionally sutured against the esophageal wall 90 degrees apart.
 
I'm sorry, but that's about all I can say about your question.  You'll have to talk to him to clarify the definition, and his answer.  One other comment about the EsophyX device: it is a single-use instrument, and costs nearly $5,000.  Fewer and fewer insurance companies are offering the coverage for this equipment purchase.
 
-Bruce

Dave234
Regular Member


Date Joined Oct 2011
Total Posts : 338
   Posted 1/29/2013 1:10 PM (GMT -6)   
Cmac, that is hilarious - you and I actually have the same surgeon! (I saw one of your other posts with his name)
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