Fundoplication is a surgical procedure in which the top of the stomach is wrapped around itself to prevent reflux. When the stomach is wrapped fully, it is referred to as a Nissen fundoplication (also called a Nissen, Nissen fundo, fundo, or just fundoplication). When the stomach is only partially wrapped, it is called a partial fundoplication.
This surgery is not required when getting a G-tube placed. It may be advised in instances when a child has severe reflux-related airway problems or when there is severe damage to the esophagus from reflux. Children who are aspirating secondarily (meaning they are aspirating their reflux) seem to be the best candidates for the Nissen. These children have likely had aspiration pneumonia, or are having breathing difficulties because of aspiration, or are turning blue.
Children who vomit a lot or who have delayed gastric emptying or gastroparesis are often not good candidates for a fundoplication. The fundoplication doesn’t address the cause of the vomiting, which is related to how slowly the stomach empties. In these children, fundoplication turns the stomach into a little pressure cooker. The contents of the stomach can no longer go up with a functioning fundoplication, and poor motility means they also cannot go down. Instead, you end up with a smaller stomach, and its contents don’t move in either direction. Kids in this situation tend to retch or have ongoing abdominal discomfort or pain. These children also tend to have more complications with vomiting past the fundoplication, the fundoplication slipping and needing to be redone, or the fundoplication herniating after it slips. A gastrojejunal tube (GJ-tube) may be an alternative to a fundoplication, or should be tried before moving forward with the procedure.
Children with neurological issues also tend to do much worse with Nissens, so these children should only receive a Nissen when the benefit clearly outweighs the risks. The GJ-tube would be a better alternative to consider.
Parents should discuss the procedure with their doctors and research the procedure before committing to a fundoplication. Note that the procedure cannot be reversed fully. Surgeons can only reconstruct the stomach as best as possible, but even this may result in additional nerve damage and complications. Few surgeons are willing to even attempt a fundoplication take down.
These images show a Nissen Fundoplication. The first illustrates the surgeon beginning to wrap the stomach around itself, and the second shows a completed fundoplication.
Does every child with a G-tube need a Nissen fundoplication?
In the past, almost every child receiving a G-tube also received a Nissen fundoplication. This is no longer standard of care. Fundoplication surgery should only be performed in children when the benefits outweigh the risks.
Burping and Vomiting
Fundoplications often inhibit a child’s ability to burp and vomit, at least temporarily. Many children require frequent venting for gas, as well as for stomach fullness that would lead to vomiting in a child without a fundoplication.
Conjunction with G-tube Placement
Some GIs and Surgeons are very pro-Nissen and will only do G-tubes in conjunction with them. This practice seems to be declining given the potential for complications in children who aren’t good candidates for the procedure. Many others are on the opposite camp and will only perform them under very specific circumstances. As a parent considering a Nissen Fundoplication, you should know that it isn’t a requirement to get one when getting a G-tube. That being said, reflux can often develop after the G-tube surgery, which is why some surgeons suggest them proactively.
The decision to get a Nissen Fundoplication is a big one. It is another surgical procedure and one that may have complications down the line, such as dumping syndrome, hiatal hernia, and even nerve damage. Be sure to ask your child’s doctor for details on potential complications and risk factors to help you make an informed decision.
Types of Fundoplications
There are different types of Nissen Fundoplications, including a complete wrap and a partial wrap. You should consult with a medical professional to better understand which they are recommending for your child and why.
No more aspiration from the stomach
For many, no vomiting from reflux, which can lead to better weight gain
Increased quality of life for you and your child
Often can be done laproscopically
When your child needs to throw up, he may retch, which is uncomfortable
The Nissen can slip, which can be dangerous and requires additional surgery
The Nissen can loosen and may need to be redone through additional surgery
Some children vomit through the fundoplication or continue to have reflux even after the procedure
Some have bloating problems where they need a lot of venting of the G-tube
Some children get dumping syndrome as a result, especially if they also have a pyloroplasty
Children with delayed gastric emptying/gastroparesis may end up using a GJ-tube even after having a fundoplication
Some surgeons will not perform these laproscopically
The surgery cannot be fully reversed; instead, the stomach must be reconstructed
A Pyloroplasty is an additional surgery that is sometimes performed in conjunction with G-tube placement or a Nissen fundoplication. In some cases, it may also be done as a stand-alone procedure.
The pylorus is the valve between the stomach and the small intestine. In some children, the pylorus does not open easily, spasms, or has thickened. This can block stomach contents from flowing into the intestine. Children may vomit, reflux, or have delayed gastric emptying. In some cases, there may be little to no movement of stomach contents into the intestine, which is called gastroparesis.
Surgeons may widen the pylorus surgically, called a Pyloroplasty, in order to help the stomach empty more readily. While this procedure is usually performed with an open incision in the abdomen, it can also be performed laproscopically. Typically, children are placed under general anesthesia. When the surgery is performed as a stand-alone procedure, pain is usual moderate after the procedure, and children rarely need more than 1-2 days in the hospital. If it is performed in conjunction with other surgical procedures, pain may be more significant, and the hospital stay may be longer.
Risks and Complications
There are risks to Pyloroplasty surgery. The most common complication is that feeds pass too quickly into the small intestine, which may cause a condition called Dumping Syndrome. Bile may also reflux upwards into the stomach.
An alternative to Pyloroplasty surgery is to try Botox injections into the pylorus, usually during an endoscopy. These injections cause the pylorus to relax and loosen. Botox typically only lasts for 1-3 months, so the procedure may need to be repeated again. Often, a trial of Botox can help a doctor or surgeon predict the success of a Pylorplasty, so Botox may be tried first.
Rarely, young infants aged about 6-12 weeks may develop a condition called Pyloric Stenosis, which causes the pylorus to thicken. This is a life-threatening emergency. If a baby suddenly stops tolerating feedings and is vomiting continuously, take him or her to the emergency room immediately. The baby will likely require a similar surgery to a Pyloroplasty, typically called a Pyloromyotomy, in which the pylorus is cut vertically.