Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Fundoplication, Esophageal


Related Terms

  • Laparoscopic Fundoplication
  • Nissen Fundoplication

Specialists

  • Gastroenterologist
  • General Surgeon

Comorbid Conditions

Factors Influencing Duration

There is a significant difference in the duration of disability between those individuals having laparoscopic fundoplication surgery and those having open fundoplication surgery. Other factors influencing duration include the age and health of the individual and any post-surgical complications that may arise.

Medical Codes

ICD-9-CM:
44.66 - Other Procedure for Creation of Esophagogastric Sphincteric Competence; Fundoplication, Gastric Cardioplasty, Nissens Fundoplication, Restoration of Cardio-esophageal Angle
44.67 - Laparoscopic Procedures for Creation of Esophagogastric Sphincteric Competence; Fundoplication; Gastric Cardioplasty; Nissens Fundoplication; Restoration of Cardio-esophageal Angle

Overview

Nissen's or esophageal fundoplication is a surgical technique used to treat gastroesophageal reflux disease (GERD). GERD is a disorder where the acidic contents of the stomach backflow (reflux) into the lower end of the esophagus. Normally a muscle called the lower esophageal sphincter (LES), located where the esophagus empties into the stomach, keeps the opening to the stomach closed except when swallowing. This prevents the contents of the stomach from re-entering the esophagus. A number of conditions can cause the LES to form an insufficient barrier between the stomach and the esophagus. As a result, the acidic stomach contents enter the esophagus and irritate it. Symptoms include heartburn, regurgitation of stomach contents, and difficulty swallowing. Occasionally the stomach contents are inhaled into the lungs, causing GERD-induced asthma and hoarseness. If irritation of the esophagus continues for a long time, a precancerous condition called Barrett's esophagus can develop.

Initially GERD is treated with lifestyle modifications. The most important lifestyle modification is weight loss. Also important is a change in diet (avoiding alcohol, caffeinated beverages and other acidic foods), eating smaller portions, avoiding food several hours before bedtime, and raising the head of the bed 6 to 8 inches. These lifestyle modifications are usually made in conjunction with treatment by proton pump inhibitor drugs (PPIs) that suppress acid production in the stomach. This regimen controls GERD symptoms in about 95% of individuals (Friedman).

If lifestyle modification and medication do not produce relief from GERD, fundoplication may be considered. This surgery wraps the top of the stomach (the fundus) around the lower end of the esophagus to give it more support and keep the opening between the stomach and the esophagus closed except during swallowing. Nissen's fundoplication is the standard procedure and involves a 360-degree wrap of the stomach around the esophagus. This procedure can be performed either with open or laparoscopic surgery.

Fundoplication has enjoyed increased popularity since the late 1990s, but differences of opinion exist in the medical community about who should have fundoplication and whether open surgery or laparoscopic surgery is more effective. Some physicians advocate fundoplication for individuals under age 40, even if their GERD is manageable with PPIs (Evangelisto). Their argument is that this low-risk surgery is more cost effective and frees the individual from a lifetime of treatment with medication. The other side claims that although in the short term individuals who have fundoplication no longer need PPIs, after 10 years, 62% of individuals who have had antireflux surgery are again taking PPI medication for GERD (Friedman).

The other controversy involves the balance between long-term effectiveness and complications of open surgery vs. laparoscopic surgery. The advantage of laparoscopic surgery is that the surgery is less invasive and recovery time is short. However, some studies have found a significant increase in the number of individuals who develop difficulty swallowing (dysphagia) after laparoscopic surgery compared to individuals who have open surgery. In addition, newer endoscopic treatment using radiofrequency heating (Stretta procedure) or endoscopic gastroplasty (endocinch procedure) may make fundoplication a less attractive option in the future.

Source: Medical Disability Advisor



Reason for Procedure

Fundoplication is performed to strengthen the lower esophageal sphincter and alleviate symptoms of GERD.

Source: Medical Disability Advisor



How Procedure is Performed

The main difference between open and laparoscopic Nissen's fundoplication is the size of the incision. Once the surgeon is in the abdomen, the procedures are similar. Open surgery is usually done in a hospital, while laparoscopic surgery can be done in a surgical center. With open surgery, the surgeon makes an 8 to 10 inch (20 to 25 cm) midline incision in the abdomen. In laparoscopic surgery, the surgeon makes five small buttonhole incisions in the abdomen through which a laparoscope is then inserted.

If the individual has a hiatal hernia, a common condition in which part of the stomach protrudes (herniates) into the chest cavity through at spot where the esophagus passes through the diaphragm, it is repaired before proceeding with the fundoplication. Next, the surgeon frees the upper part of the stomach (fundus) from the surrounding tissue. The surgeon then pulls a few centimeters of the top of the stomach behind and around the esophagus (360°) and uses three stitches to secure the stomach to the base of the esophagus. This serves to reinforce the lower esophageal sphincter so that it will now form a functional barrier to the stomach contents.

Individuals having open surgery usually remain in the hospital 5 to 7 days, while those having laparoscopic surgery remain 2 to 3 days, although sometimes laparoscopic surgery is performed on an outpatient basis and the individual returns home the same day.

After surgery, the individual begins with a liquid diet, gradually progressing to soft food, then regular food over the course of a week or so.

Source: Medical Disability Advisor



Prognosis

In the short term, fundoplication relieves symptoms of GERD in 85% to 90% of individuals when performed by experienced surgeons (Bais). However, in the long term, symptoms may return and individuals will need to take PPI medications to control them. There appears to be no significant difference between open and laparoscopic surgery in the relief of symptoms, but 1% to 8% of individuals have difficulty swallowing following laparoscopic surgery (Galmiche).

Source: Medical Disability Advisor



Complications

Complications of surgery include bleeding and infection. Other complications include reduced esophageal motility and difficulty swallowing after surgery. Over time, the stomach wrap may loosen, and symptoms of GERD may return.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Individuals who have laparoscopic surgery have minimal restrictions upon returning to work. Individuals who have open surgery will need to refrain from strenuous activity and heavy lifting and may need to be reassigned to activities that are more sedentary for up to 8 weeks.

Source: Medical Disability Advisor



References

Cited

Bais, J. E. "Laparoscopic Conventional Nissen Fundoplication for Gastroesophageal Reflux Disease: Randomized Clinical Trial." Lancet 355 9 (2000): 170-170.

Evangelisto, Mary. "Permanent Relief for Heartburn Sufferers." Today's Surgical Nurse 19 1 (1997): 22-28.

Friedman, Lawrence S. "Gastroesophageal Reflux Disease (Heartburn)." Sensitive Gut (Harvard Special Health Reports). Stanford: Harvard Health Publications, 2002.

Galmiche, J. P., and F. Zerbib. "Antagonist: Laparoscopic Fundoplication is the Treatment of Choice for Gastro-oesophageal Reflux Disease (Debate)." Gut 51 4 (2002): 472-475.

Patti, Marco, and Urs Diener. "Gastroesophageal Reflux Disease." eMedicine. Eds. John Gunn Lee, et al. 3 Sep. 2004. Medscape. 29 Oct. 2004 <http://emedicine.com/med/topic857.htm>.

Source: Medical Disability Advisor






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