As things died down from the bleeding episode, we headed back to Philly. While the bleeding was not attributed to his fundoplication surgery, the Radiologist did see a hernia. This was not was the radiograph was meant to look for, but happen to stand out. The surgeon at CHOP said it was a good find for him to see it on the radiograph. Hernias are usually confirmed by upper GI tests, using barium.
The surgeon at CHOP wanted to confirm that this was not a misread on the radiograph, so back to CHOP we went. The doctor wanted to make sure that the fundo had not torn and caused the bleeding. When we arrived for the appointment, he too agreed that the bleeding incident was from the Nasonex... we get it...... IT WAS THE NASONEX!
Unfortunately, Ian does have a hiatal hernia. He has herniated the Nissen surgery that was done September 2011. It is a small hernia, but part of the stomach has come through the “wrap” that was done and is now above his diaphragm. A side view during the upper GI series showed it very well.
While the surgeon does not think it had anything to do with the bleeding episode, it does present a problem. Currently, Ian is not have any reflux symptoms from the loosened fundo wrap, nor does he have current dysphagia (painful swallowing). Because of this, he does not feel as though it needs surgical correction at this time.
He believes that this hernia is from all the retching Ian did before we were able to get his blood sugar under control and help the emetic (vomiting) reflex in the brain with Benadryl. He also believe that the hernia was probably beginning back in November. If you’ll remember, right before Thanksgiving, Ian spit up for the first time past his surgery. This means loosening, and can mean problems. An upper GI was performed and no hernia was seen.
However, as noted by the surgeon, the November upper GI series was done only by inserting barium through Ian’s G tube to see if it would come up past the surgery. This time, in addition to inserting barium through the G tube, some was syringed into his mouth as he could swallow it. This allowed the Radiologist and the surgeon to see both angles. The doctor said this study was carried out better than the previous one. He believes that if the November study had been done this way, we may have seen the hernia beginning. The surgeon at CHOP that requested the November study was not the surgeon we see now. The request may have been different from our current surgeon.
Since Ian is currently not having any issues with the hernia, it can wait. The surgeon did tell us that in a few months, or couple years, it will need to be repaired. He said if reflux symptoms return or it is causing pain, then it may be sooner. In order to fix this hernia, the surgery needs to be “undone.” The surgeon will go in and undo the wrap created in September. The hernia will be corrected, then, he will “re-wrap” the top of the stomach around the base of the esophagus, again. However, this time, will be different.
As this is not the same surgeon who did the Nissen in September, the surgery will be a little different. According to the surgeon at CHOP, may studies and papers are published about the various types of fundoplciations and their side effects. Nissens are 360 degree wraps and the stomach goes all of the way around the esophagus before it is stitched. This time, the surgeon will be doing a “Toupet.” This type of wrap is a 270 degree, or a three-quarter, wrap.
Here are images for the Nissen versus Toupet wraps:
According to these various papers and studies, Toupet wraps are as efficient as Nissens, and have fewer side effects. Ian’s post-prandial hypoglycemia issues were mostly the result of gastric surgery. It is called “late-dumping syndrome.” Ian’s “sugar-stat” was unstable before surgery, but the gastric surgery exacerbated it considerably! Apparently, this is a more common side effect of gastric surgeries than most people think. It contributed to most of the retching Ian did. Seeing as though we were told by several GI doctors in our home area that “retching syndrome” was a gastric surgery side effect and it would simply go away after a few years on it’s own, I was not pleased to hear this from CHOP! Thankfully, all of Ian’s feeding regime monitoring to control the blood sugar had helped this side effect tremendously!!!
So when Ian’s surgery is redone, a 270 degree wrap will be completed. I was also given the impression that this will help swallowing and eating in the future, as the esophagus will not be as “tight.” As we left the office, we imagined our only issue over the next few days would be some constipation from the barium... boy, oh boy, were we wrong..................