Perspectives in clinical gastroenterology and hepatology
Gastroesophageal Reflux Disease Treatment: Side Effects and Complications of Fundoplication

https://doi.org/10.1016/j.cgh.2012.12.006Get rights and content

Even skilled surgeons will have complications after antireflux surgery. Fortunately, the mortality is low (<1%) with laparoscopic surgery, immediate postoperative morbidity is uncommon (5%–20%), and conversion to an open operation is <2.5%. Common late postoperative complications include gas-bloat syndrome (up to 85%), dysphagia (10%–50%), diarrhea (18%–33%), and recurrent heartburn (10%–62%). Most of these complications improve during the 3–6 months after surgery. Dietary modifications, pharmacologic therapies, and esophageal dilation may be helpful. Failures after antireflux surgery usually occur within the first 2 years after the initial operation. They fall into 5 patterns: herniation of the fundoplication into the chest, slipped fundoplication, tight fundoplication, paraesophageal hernia, and malposition of the fundoplication. Reoperation rates range from 0%–15% and should be performed by experienced foregut surgeons.

Section snippets

General Mortality, Morbidity, and Conversion Rate to Open Operation

By all measures, laparoscopic antireflux surgery is a safe operation when performed by experienced surgeons. Postoperative 30-day mortality is rare, and among available reports it is usually <1%.1 By using the U.S. Nationwide Inpatient Sample (20% stratified sample of U.S. nonfederal hospitals recording 5–8 million hospital stays from about 1000 hospitals each year), we reported the inpatient mortality after antireflux surgery decreased from 0.82% in 1993 to 0.26% in 2000, but it increased to

Acute Perioperative and Immediate Postoperative Complications

Poor functional outcome after antireflux surgery usually can be traced to inadequate patient selection or technical problems encountered during the operation. In other cases, a different set of complications become manifest clearly during the operation or immediately postoperatively and potentially can lead to significant morbidity if not immediately recognized and treated.12

Gas-bloat Syndrome

The gas-bloat syndrome comprises an ill-defined and variable group of complaints assumed to result from the inability to vent gas from the stomach into the esophagus after fundoplication. The predominant complaint is bloating, but other symptoms include abdominal distention, early satiety, nausea, upper abdominal pain, flatulence, inability to belch, and inability to vomit. The cause of the syndrome is unclear, but proposed mechanisms include (1) inability of the surgically altered

Revisional Antireflux Surgery

Although long-term results with antireflux surgery are generally good, especially if performed by experienced surgeons, failures are unavoidable. Most failures occur within the first 2 years of the initial operation.1 In large reviews, the most common symptoms are recurrent heartburn and/or dysphagia, with pain and bloating being less common.10, 42

Figure 1 illustrates several of the primary patterns of fundoplication failures.43 Herniation of the fundoplication into the chest (type 1A) is the

Conclusions

The success of antireflux surgery requires disciplined cooperation between the gastroenterologist and surgeon to avoid potential pitfalls (Table 2). The gastroenterologist must select the appropriate patients on the basis of careful and thorough esophageal function testing. The surgeon must be skilled in the technical nuances of laparoscopic surgery and not reluctant to convert to an open laparotomy when problems occur. Nevertheless, complications occur after antireflux surgery. The

References (46)

  • N. Malhi-Chowla et al.

    Dilation after fundoplication: timing, frequency, indications and outcome

    Gastrointest Endosc

    (2002)
  • J.M. Hui et al.

    Esophageal pneumatic dilation for post fundoplication dysphagia: safety, efficacy and predictors of outcome

    Am J Med

    (2002)
  • A. Klaus et al.

    Bowel dysfunction after laparoscopic antireflux surgery: incidence, severity and clinical course

    Am J Med

    (2003)
  • L. Swanstrom et al.

    Spectrum of gastrointestinal symptoms after laparoscopic fundoplication

    Am J Surg

    (1994)
  • J.A. Dominitz et al.

    Complications and antireflux medication use after antireflux surgery

    Clin Gastroenterol Hepatol

    (2006)
  • R.V. Lord et al.

    Absence of gastroesophageal reflux disease in a majority of patients taking acid suppression medications after Nissen fundoplication

    J Gastrointest Surg

    (2002)
  • B.P. Wijnhoven et al.

    Use of antireflux medication after antireflux surgery

    J Gastrointest Surg

    (2008)
  • J.B. So et al.

    Outcomes of atypical symptoms attributed to gastroesophageal reflux treated by laparoscopic fundoplication

    Surgery

    (1998)
  • K.F. Hatch et al.

    Failed fundoplications

    Am J Surg

    (2004)
  • L.L. Swanstrom et al.

    Laparoscopic Collis gastroplasty in the treatment of choice for the shortened esophagus

    Am J Surg

    (1996)
  • D. Stefanidis et al.

    Guidelines for surgical treatment of gastroesophageal reflux disease

    Surg Endosc

    (2010)
  • C.D. Jensen et al.

    Day-care laparoscopic Nissen fundoplication

    Surg Endosc

    (2009)
  • F. Pizza et al.

    Influence of age on outcome of total laparoscopic fundoplication for gastroesophageal reflux disease

    World J Gastroenterol

    (2007)
  • Cited by (154)

    • Robotic-assisted versus laparoscopic redo antireflux surgery in children: A cost-effectiveness study

      2023, International Journal of Medical Robotics and Computer Assisted Surgery
    View all citing articles on Scopus

    This article has an accompanying continuing medical education activity on page e39. Learning Objective—At the end of this activity, the successful learner will be able to identify and treat the common complications and side effects after antireflux therapy.

    Conflicts of interest The author discloses no conflicts.

    View full text