Is the Nissen Fundoplication for GERD Worth it?
By Stu Leo︱Published July 24, 2022
You’re gripped with anxiety. You’ve been suffering from acid reflux for years and want to stop taking PPIs because of the side effects. At the same time, you’re concerned about the risk of cancer. The thought of not being there for your kids scares you…
Should you just get the Nissen Fundoplication surgery to put an end to your reflux once and for all? Will it be worth it? That’s what we’ll discuss in this article.
What is a Nissen Fundoplication?
First, let’s go over the Nissen’s history and talk about what this surgery entails.
The Nissen was originally a makeshift surgery a German doctor named Rudolf Nissen apparently made up on the spot in 1955 in order to stop acid reflux in a woman who had esophagitis. The surgery became famous soon after and remains the “gold standard” for anti-reflux surgery today:
So what exactly is a Nissen Fundolipication?
A Nissen Fundoplication is an antireflux surgery where they take the top of your stomach called the fundus, bring it around your lower esophagus, and sew it to itself and to your esophagus to create a wrap:
The above picture and pretty much all depictions of the Nissen is really a sanitization of what this surgery really looks like. The reality is the Nissen is a bloody, messy procedure where they have to cut through a bunch of tissue. Here’s a video from Youtube if you want to check it out for yourself.
Warning: Not for the queasy, or those who are disturbed by blood. You have been warned.
The Truth about Reflux, Barrett’s, and Cancer
Unfortunately, what most people don’t know is the progression of acid reflux to Barrett’s Esophagus is low(most studies put the risk at about 5 to 15%).
Same thing with esophageal cancer, except it’s even lower, at about 0.1 to 0.5% annually.
Moreover, the majority of people who get Barrett’s Esophagus and esophageal cancer HAVE NO ACID REFLUX SYMPTOMS AT ALL. This is evidenced by the fact that researchers have found seventeen times more Barrett’s in dead people who never had GERD than they have discovered with GERD patients they scope with a camera.
With regards to esophageal cancer, the majority of cancer patients(96.1%!) DO NOT even know they have Barrett’s Esophagus because many never experience GERD symptoms!
This is a problem because it suggests there are more factors at play in cancer risk that we’re missing entirely.
That’s not to say that GERD does not increase the risk for complications; most studies affirm this. It is to say that the risk for Barrett’s Esophagus and esophageal cancer due primarily to GERD symptoms, is much lower than some would have you believe.
Keep this in mind as I go through the potential risks and side effects of the Nissen Surgery.
Is it really worth potentially destroying your life and getting possibly lifelong side effects to mitigate a .01% to 0.5% cancer risk?
There might be significant and life-altering side effects
What many people don’t realize going into anti-reflux surgery, particularly the Nissen Fundoplication, is that they may experience significant side effects afterward, given the invasiveness and extreme nature of the surgery.
If you watch the surgery video above you would have seen a bloody mess. In order to conduct a Nissen, you have to slice through a bunch of tissue including blood vessels, diaphragm muscle, and immunoprotective tissue(called the omentum).
Will these tissues grow back the same? Is blood flow impacted? Hard to know for sure because most surgeons and patients probably don’t want to be opened up again to find out.
So yes, there are risks and potential complications—don’t let anyone tell you otherwise.
I know many people who are constantly suffering from Nissen side effects and many people who were never told about any potential risks associated with the Nissen Fundoplication.
If you feel you are being pressured and scared into getting surgery, it would be wise to get a second or third opinion from doctors who maybe are not full-time gastric surgeons for unbiased medical advice.
Let’s start with the most serious potential Nissen complication: vagus nerve damage.
First, what is the vagus nerve? The vagus nerve is a long nerve that runs from your brain all the way down into your stomach area. It is an incredibly important and complex nerve that is crucial for a variety of functional tasks in the body, including but not limited to digestion, coughing, swallowing, sneezing, vomiting, breathing, heart rate, organ function, emotion control, and probably way more we do not fully understand yet or know about:
OK, so here’s the thing. As I’ve said already, the vagus nerve runs through to the stomach. So when the surgeon is poking around inside your abdomen, slicin’ and dicin’ away to get to the stomach to make the wrap, there is a chance that they could slice and dice your vagus nerve accidentally. That’s understandable because the operating space is small and delicate.
I mean just lift up your shirt and take a look at your stomach right now. The surgeon will be sticking relatively small laparoscopic arms into small incisions on your belly, and they’ll be attempting to wrap your stomach around your esophagus via camera.
Because of how close the vagus nerve is to the surgery site, I’d imagine it would not be hard to accidentally damage the vagus nerve in the process.
And this study from Leiden University Medical Center in the Netherlands bears this out. According to the authors, signs of vagus nerve damage are present in 10% of Nissen Fundoplication patients.
They claim that this vagus nerve damage did not affect how fast the patients digest food(in some cases gastric emptying accelerated), but who really knows 5, 10, or 15 years later?
As I mentioned before, the vagus nerve is CONNECTED TO YOUR BRAIN. Though the risk for vagal nerve damage is low—especially if you get an experienced surgeon—do you really want to find out?
DID YOU KNOW…
Vagus nerve damage is often required to do the Nissen Fundoplication properly:
In other words, the vagus nerve near the upper stomach is likely to get damaged intentionally to give the surgeon enough room to perform the Nissen.
Is it possible for a surgeon to perform the Nissen without dissecting the vagus nerve? Maybe, but to me, it looks unlikely given how close the vagus nerve is to the stomach:
Here is another angle of the vagus nerve, again quite close to the stomach:
Also, did you know that the hepatic anterior vagus nerve is connected to the gallbladder? Take a look at the green organ to the left in this picture:
See how the gallbladder is connected to the vagus nerve? This is why gallbladder damage/malfunction after a Nissen or hiatal hernia surgery is more common than you may think:
As you can see from the excerpt above, “cutting”(a.k.a. destroying) the vagus nerve apparently increases gallbladder emptying time, and promotes kidney stone formation. Is this supposed to be OK?
General Side Effects
They are: difficulty swallowing, bloating, inability to burp or vomit(what’s gonna happen if you get food poisoning?) stomach pain, suppressed appetite, nausea, dizziness, fatigue, cold sweats, diarrhea, and possibly more.
Plus there are supposedly “short-term” food restrictions immediately after surgery. Why the restrictions? It’s because the Nissen is itself a restrictive surgery:
Look at the picture above. The wrap literally restricts the upper stomach from stretching as normal stomachs do. So when you eat foods that may cause even a bit of gas, this can cause massive discomfort or even pain.
The stomach tries to distend or stretch, but it can’t because it’s sewn to itself around the lower esophagus.
That’s why most guides for after the surgery will tell you not to eat bread, rice, beans, nuts, bananas, berries, pineapple, raisins, raw veggies, peas, broccoli, cabbage, corn, cucumber—or even chew gum—until “after you heal”…maybe?
Join a Nissen forum to hear about all the people who can no longer eat fruit anymore after surgery. Again, this is because the Nissen artificially prevents your stomach from stretching as normal stomachs do when digesting plants.
It is for this reason that I call the Nissen Fundoplication “Death Trap #2” because the surgery restricts your body from processing plant foods that are actually good for you and can lower cancer risk.
Instead, you are confined to eat, for the most part, processed junk food:
*If you have had a failed Nissen by the way, I’m not trying to make you feel bad or discourage you. Personally, I believe the human body is capable of great feats and its natural state is to heal.
This is also why in my experience, doctors are actually pretty evenly split over recommending the Nissen Fundoplication—especially to a younger person. Heck, there may even be a strong bias towards not getting surgery.
I’ve found, oftentimes, the people pushing surgery on the internet are the very surgeons who perform the Nissen. In real-life though, the day-to-day doctors are typically more cautious, conservative, and honest about surgery.
But here’s a fun little experiment you can try if you are seriously considering the Nissen Fundoplication and are doubting potential side effects. Draft up a contract that guarantees improvement of your GERD symptoms and NO adverse side effects by whatever percentage the surgeon is claiming.
Tell them to sign it.
SURPRISE! They won’t put their name down on ink because there is no such guarantee of success.
In fact, they will HAVE YOU SIGN documents to not hold them liable if the surgery fails!
Furthermore, many surgeons will downright turn you down and probably refer you to a specialist if you want to have the procedure undone because reversing the surgery is risky and another big liability.
So the real question is NOT what are the odds that my Nissen Fundoplication surgery will be a success, but whether you can live with debilitating bloating, gas, pain, and even more food restrictions for the rest of your life.
You’ll have to talk to a good doctor and family members(who will take care of you if your surgery fails?) whom you trust to make the right decision for yourself.
A Closer look at Nissen Surgery “Success” Rates
Is the doctor now chuckling while squirming in his seat and readjusting his collar? This will also help you make the right decision.
And if you feel like my fun little experiment above is too intense, just ask the surgeon to take you through the event where your surgery fails or you get horrible life-altering symptoms that have worsened your quality of life—what then?
Will they be able to modify the surgery or reverse it? Or will they just send you to someone else? How much will this cost?:
So most Nissen studies claim surgery success rates are high(around 90%). Is this true, or is there more to the story?
Well, first off, most of these studies are 5-year follow-ups. I’m not interested in only 5-year follow-ups, but also in the 10-year, 15-year, and even 20-year follow-ups. If you don’t really experience reflux symptoms a few years after surgery but then experience recurrent symptoms 5 years later when your kids are older that inhibits your ability to be there for them fully—can you really call that a success?
How bout further down the road when you want to take a vacation with your family? Will the side effects of a Nissen prevent you from doing that? How about 15 years later? 20 years later? Will you be able to be fully present with your grandchildren and actually enjoy your golden years in good health? Or will you be struggling with the consequences of anti-reflux surgery? These are some questions worth asking before making your final decision.
One more point before we dive into the studies: 90% isn’t 100%.
Meaning there are still at least 10% of Nissen patients who apparently aren’t experiencing adequate relief from their acid reflux symptoms.
If acid reflux is due simply to a defective lower esophageal sphincter, tightening the sphincter should fix the issue, shouldn’t it? The success rate for the Nissen should be near 100%, not just 80-90%.
This highlights the necessity of running tests to make absolutely certain that a patient has acid reflux before performing surgery. It also highlights the fact that researchers still don’t know exactly how acid reflux works.
Nissen Success Rates
Basically, Nissen success rates range from 62% to about 90%:
Why the disparate range? It’s partly due to how people are defining success.
Does surgery success mean that I don’t have to take PPIs anymore?
Or does it mean asking the post-operative patient whether they think the surgery was worth it?
Personally, if I still had to take PPIs after getting surgery I would objectively consider that a big fail. But many studies don’t measure success that way. Instead, they ask the patient whether or not they are “satisfied” with the surgery.
But let me ask you this: If the patient believes that their only choice is surgery or get esophageal cancer in the long run—what do you think they’ll say?
Here’s what a study from Flinders University Department of Surgery had to say about how Nissen patients interpreted surgery success:
Again, if the patient is convinced into thinking the symptoms they’re experiencing after surgery are better than getting cancer in the long run with no surgery, they are more likely to say that the surgery was worth it and “Yes, I would do it again.”
But if you were told that there was a 10% to 38% chance that you would get side effects and/or have to take PPIs despite getting a Nissen Fundoplication, would you still go through the surgery? Are you the type of person who would risk your life(however small the risk) for the thrill of a skydive?
Because as the numbers stand right now, the risk for surgery failure is much greater than the risk of dying in a skydive(1 in 220,301).
For me, the stats simply don’t inspire confidence, and I haven’t even included the numbers for revision surgeries(which are substantial).
The Nissen Fundoplication Sucks even more for LPR
According to the American College of Gastroenterology, LPR patients who get the Nissen Fundoplication do not experience resolution of their symptoms. The range of symptom improvement is cited at 15% to 95%.
In other words, completely random:
Here’s another study the ACG cites that puts the surgery success rate for LPR patients even lower at just 10%:
Studies indicate that the recurrence of symptoms after surgery is much more likely for LPR and extraesophageal symptoms than the typical symptoms of heartburn and regurgitation.
Could this have something to do with the fact that GERD has been massively overdiagnosed since the 90s?
Lastly, the ACG sums up their guidance on LPR and the Nissen Fundoplication by saying:
DID YOU KNOW…
Did you know the Nissen Fundoplication surgery irreversibly damages or “alters” your upper stomach region? It makes sense when you think about it. The surgery is literally done by hacking through a bunch of stomach tissue and sewing your stomach TO your stomach AND to your esophagus.
Then your stomach readjusts and stretches out to its new position. It’s a bloody mess. This is why most surgeons will refuse to reverse or “take down” a Nissen once it has been done.
The research on Nissen takedowns is basically non-existent as far as I can tell, but I’d imagine the reason why most surgeons would not want to do a Nissen reversal is because it’s quite risky:
Go back and look at the Nissen demonstration video I posted above. The stomach is sewn to itself and to your esophagus with reinforced synthetic thread.
How exactly would you cut through hardy synthetic material without damaging the stomach and the esophagus? And let’s say you were able to undo the sewn-in polymer thread—does the stomach revert back to its original form, or does it remain bloody, scarred, and stretched? How does this now affect digestion?
Understand that the Nissen Fundoplication may very well be permanent and irreversible depending on your accessibility to the few doctors who are willing to take on the liability and risk of taking down a Nissen.
You ready for that?
Oh, and by the way, researchers who performed Nissen Fudoplications on pigs found that the surgery restricted blood flow to their kidneys by about 36%.
Does this translate to humans?
Our McDonald’s Culture
The massive advancement of technology and prosperity in the 20 and 21st century has shifted our cultural attitude. We are by nature impatient creatures, wanting results yesterday, but it seems that cultural attitude is much more pronounced today.
Today, I can get a burger at McDonald’s in my mouth in just under 4 minutes via drive-through. I can get directions to a state park on my phone in half that time with just my voice, driving and shoveling that big mac down my throat—no typing required. Many of us seem to expect the same when it comes to healing chronic diseases.
Change of lifestyle? Forget that. No, I want a solution that’s fast, easy, and requires minimal effort. That’s the state of our fast-paced Western culture today.
But do you want to know the truth?
The truth is there are no shortcuts to good health. There is no fast-paced, drive-through option to heal acid reflux.
Unfortunately, many people believe that the Nissen Fundoplication is their fast-paced, drive-through shortcut to recovering from acid reflux once and for all and are left sorely disappointed when they find out that simply isn’t true.
Now, I know some of you who are reading this post right now are thinking, “But Stu, I feel like I’ve tried everything to no avail. I’m sick and tired of not being able to talk and just live a normal life.”
Believe me, I get it. I was unable to speak without pain and discomfort for 2 years and I suffered from regurgitation every night during that time. So I understand completely.
But let me ask you a question: have you really tried everything? Have you talked to your doctor about trying a modified plant-based diet? Are you mouth breathing at night?
I talk about these lifestyle modifications and more in my free eBook you can get right here.
-The Nissen Fundoplication irreversibly damages the top of the stomach. Even if you are able to “undo” the surgery, there is no guarantee of completely healing.
-The likelihood of you not being able to eat foods you were once able to eat before surgery is considerable. This is because mechanically tightening the top of the stomach screws with the ability of your stomach to “churn” food and vent gas.
-The percentage of Nissen surgery failure(still have to take PPIs afterward) ranges wildly from 32% to 90%. This should be a big red flag.
-According to the ACG, the Nissen is less likely to work for LPR and other extraesophageal reflux symptoms than for heartburn and regurgitation.
Will the Nissen Fundoplication for GERD really be worth it?
I don’t want to find out.