GERD: Side Effects and Complications of Fundoplication

Abstract and Introduction

Abstract

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.

Introduction

In the past 15 years there has been an increase in the number of antireflux operations being performed. The reasons include the development and proliferation of laparoscopic techniques, the increase in the fraction of the population that is overweight, which worsens their gastroesophageal reflux disease (GERD), and possibly the increased willingness of the population to undergo an operation to avoid the necessity of lifetime medications or lifestyle changes. The operation is now widely available in community hospitals, the length of stay ranges between 1 and 4 days, some operations are even performed as day surgery, and most patients return to normal activity within 2 weeks.^[1,2] Similar to younger patients, reflux patients older than 65 years of age can expect an excellent outcome in at least 90% of cases after laparoscopic surgery.^[3] On the basis of the U.S. Nationwide Inpatient Sample, there were 9173 adult antireflux operations in 1993, which has increased nearly 3.5-fold, reaching a peak at 32,980 in 2000.^[4] For poorly understood reasons, the most recent available data for 2006 show a 40% decline to 19,688 operations.^[5]

This article will focus on the surgical and medical complications commonly reported after laparoscopic antireflux surgery (Table 1). The available reports on this subject are numerous, so I have relied on summary data available from the Society of American Gastrointestinal and Endoscopic Surgeons^[1] and the Agency for Healthcare Research and Quality Effective Health Care Program Comparative Effectiveness of Management Strategies for Gastroesophageal Reflux Disease: An Update to the 2005 Report.^[6] The review will summarize mortality and morbidity data for laparoscopic antireflux operations, review the common perioperative and postoperative complications, and discuss the common reasons for fundoplication failures.

Table 1. Prevalence of Medical and Surgical Complications of Antireflux Surgery
Mortality (<30 days)	1% or less
Perioperative and immediate postoperative morbidity	8%–17%
Open conversion rate	0%–24%
Early postoperative complications
Bowel perforation	0%–4%
Bleeding and splenic injury	<1%
Pneumothorax	0%–10%
Severe postoperative nausea and vomiting	2%–5%
Late postoperative complications
Gas-bloat syndrome	1%–85%
Dysphagia
Early	10%–50%
Late	3%–24%
Diarrhea	18%–33%
Recurrent heartburn	10%–62%
Need for revisional surgery
Laparoscopic Nissen fundoplication	0%–15%
Laparoscopic Toupet fundoplication	4%–10%

Table 2. Potential Pitfalls and How to Avoid
Antireflux surgery is never an emergency procedure. All patients should be carefully evaluated before surgery.
At a minimum, preoperative testing should include upper endoscopy, esophageal manometry, and pH testing (the latter primarily in patients with nonerosive GERD). Do not take short cuts.
Even skilled foregut surgeons will have complications after antireflux surgery. All patients should have a frank discussion with their gastroenterologist and surgeon about potential postoperative problems including dysphagia, gas-bloat, diarrhea, and the durability of the operation with return of heartburn or atypical reflux symptoms.
Treat these common complications with conservative therapy and never rush into redoing antireflux surgery. Most problems will improve during a period of 3–6 months.
The revision of a fundoplication operation requires a very experienced foregut surgeon. The keys to success must not be violated. These include (1) careful review of the patient's prior work-up and repeat studies as necessary, (2) recognition of esophageal shortening, and (3) complete takedown of the original fundoplication.