This is for a patient with severe GERD with previous ischemic heart disease, so anti-reflux surgery needs to be done at the shortest time possible to avoid anesthesia complications
Dear Ranga,Dor fundo can be done but it is much less effective in severe GERD.we all are well aware of three important principles of Surgery for Gerd.1.Abdominal lengthening of esophagus 2.cruroplasty to narrow the Hiatus 3. Total reenforcing the sphincter with Gastric fundus.In all these aspects Dor is not effective.Perhaps it takes extra 20 mts in your hands to do Nissan. Another important aspect is to give an effective ONE procedure as we do not get a chance to revise in High risk patients."DO less and come out" in this situation may not be advice able.
Dear Sir,
Many thanks for your advice and sharing your experience. I'll keep u posted, he is planned for Thursday
Dear Dr Rangarrajan I totally agree with Dr Prasanna. Dor fundoplication is very much less effective than Nissen fundoplication. Is PPI therapy ineffective or contraindicated?
It would be better to treat at this patient with maintenance treatment with PPIs only in my modest opinion
Thanks Dr. Santi, Dr. Rodrigo & Dr. Reddy.
I should've mentioned this earlier - patient presented with a large symptomatic groin hernia, for which he insisted on laparoscopic repair. This was the reason I planned to do a fundoplication along with the groin hernia repair. I put the problem to the patient and asked him to decide - he chose NOT to undergo the fundoplication. So I just did the hernia repair, followed by PPIs.
My lesson learnt here: patient will sometimes (maybe most of the time....) make the correct decision for us !!
The success of fundoplicato implemented in surgical techniques have seen how the intervention is related to the presence of obvious symptoms and patients who do not respond to medical therapy continues to ceilings dosages with IPP, especially in cases where persists complicated regurgitation possibly extraesofageal events , with the non-obstructive failure in the presence of dysphagia ,Nissen rossetti fundoplicatio.
The surgery needs to be done properly rather than worry about saving small amounts of anaesthetic time. The crural dissection to reduce the hernia and mobilise intra abdominal oesophagus is important. Of course there are many choices for wraps including the Dor and some evidence that there may be advantages in terms of gas bloat and dysphagia. However longer terms resolution of reflux may be worse than with a Nissen and this is also my personal experience
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