Gastroesophageal Reflux Disease Treatment

Side Effects and Complications of Fundoplication

Joel E. Richter

Disclosures

Clin Gastroenterol Hepatol. 2013;11(5):465-471. 

In This Article

Late Postoperative Complications

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 gastroesophageal junction to relax in response to gastric distention; (2) aerophagia, a frequent habit among patients with severe GERD, which becomes problematic after fundoplication when the air cannot be vented; (3) impairment of meal-induced receptive relaxation and accommodation of the stomach with rapid gastric emptying; and (4) surgical injury to the vagus nerve, which delays gastric emptying and interferes with transient relaxation that is part of the normal belch reflux.[18]

The reported frequency of gas-bloat syndrome has ranged widely from 1%–85%, depending on the definition of the disorder as well as underlying population and type of fundoplication.[6] For example, an early Veterans Affairs Hospital trial of medication and surgical therapies for GERD found by questionnaire that 81% of the surgical patients had at least 1 symptom of the gas-bloat syndrome, but the comparable medically treated patients also had a 60% rate of gas-bloat symptoms.[19] These symptoms seem to be worse with a total compared with a partial fundoplication.[8] Symptoms are worse immediately after surgery, with most improving or resolving during the first year.

Recommended therapies, albeit without convincing evidence of effectiveness, include (1) dietary modifications to avoid gas-producing foods and carbonated beverages, (2) eating slower to avoid aerophagia, (3) cessation of smoking, (4) gas-reducing agents such as simethicone, and (5) prokinetic drugs. Biofeedback mechanisms have been used to retrain patients to decrease the frequency of swallowing after antireflux surgery with some success.[20] Debilitating cases need further evaluation for small bowel obstruction caused by adhesions from the original surgery and delayed gastric emptying. Up to 40% of patients with GERD may have some element of delayed gastric emptying,[21] but antireflux surgery usually accelerates the emptying of both solids and liquids.[22]

Inadvertent vagotomy, especially common with redo fundoplications, can delay gastric emptying of solids by interfering with antral motility and pyloric relaxation. Severe cases may require surgical revision including conversion to a partial fundoplication, allowing easier gas venting, or pyloromyotomy when delayed gastric emptying is documented.[23]

Dysphagia. Some degree of dysphagia, especially for solid foods, is expected in all patients for the first 2–6 weeks after surgery. These complaints are presumably a consequence of postsurgical edema and inflammation slowing bolus transit of foods.[6] Marked dysphagia for liquids is rare and should suggest an important anatomic dysfunction. These patients are initially treated with dietary modification (soft diets, plenty of fluids) and reassurance, with the dysphagia usually resolving spontaneously within 2–3 months. However, 3%–24% of patients experience dysphagia that persists beyond 3 months that requires more than dietary management.[24] This latter group of patients usually have a fundoplication that is too tight for their functional esophageal pump, but other causative problems include previously unrecognized achalasia, healed peptic stricture, paraesophageal hernia, excessively tight crural closure, slipped fundoplication into the chest with a recurrent hernia, or distal migration of the wrap onto the stomach that creates a two-compartment stomach. Preoperative manometry is mandatory to exclude achalasia, but esophageal function testing otherwise is poor in defining those patients likely to be troubled with postoperative dysphagia.[25] Therefore, "tailoring" the type of fundoplication to the esophageal pump has lost favor, with the exception of a partial fundoplication in patients with aperistalsis.[26] Patients with dysphagia before surgery are more likely to have dysphagia after surgery, regardless of the type of fundoplication.[27]

Patients with persistent dysphagia need further investigation to determine whether the fundoplication is too tight or long vs an anatomic displacement. These tests include barium esophagogram with a 13-mm tablet, esophageal manometry, and/or endoscopy. If the fundoplication is intact, bougie and/or through-the-scope balloon dilation will relieve symptoms in one-half to two-thirds of cases, usually with one series of dilations up to 18 mm (54F).[24,28] This can be done within a month of the fundoplication and does not produce new reflux symptoms.[24] More recently, pneumatic dilation (30 to 40-mm balloons) has been advocated, if the patients fail to respond to bougie dilation and the nadir lower esophageal sphincter pressure on manometry is ≥10 mm.[29] About two-thirds of patients not responding to bougie dilation with tight fundoplications will respond to pneumatic dilation. The remainder will need revision surgery that converts the complete fundoplication to a partial wrap. On the other hand, patients with slipped fundoplications or paraesophageal hernias usually will require reoperation because less than 30% respond to bougie dilation alone.[24]

Diarrhea and Flatulence. Diarrhea is a frequent complication of fundoplication that is often not discussed before surgery. In a study of 84 patients responding to a telephone survey after antireflux surgery, 15 (18%) described the new onset of diarrhea.[30] The diarrhea usually developed within 6 weeks of the operation and was mild and low volume (2–4 bowel movements/day) and worse after meals. In 4 patients it was associated with fecal incontinence. In this study, only 2 of 15 patients (13%) had complete resolution of their diarrhea after 2 years. Other reports describe rates as high as 33%, but these studies do not describe whether the diarrhea was present before surgery.[31] The cause of post-fundoplication diarrhea is not known. Proposed mechanisms include (1) rapid gastric emptying from the fundoplication overloading the small intestine's ability to handle the osmotic bolus, the dumping syndrome, (2) vagal injury with subsequent small bowel overgrowth, and (3) exacerbation of underlying irritable bowel syndrome.[30] Antimotility agents including codeine, antibiotics for small bowel overgrowth, and cholestyramine may ease the diarrhea, but the management is empirical.

Flatulence has been reported in 12%–88% of patients after antireflux surgery.[31,32] This increase in flatulence is attributable to the patients' inability to belch and subsequent passage of more gas into and then through the gastrointestinal tract.[32] As with the gas-bloat syndrome, the true risk after surgery is unknown, because many studies only surveyed patients after surgery and asked them to recall how they were before the surgery (recall bias).

Recurrent Heartburn. The durability of antireflux surgery has recently been the topic of much interest and evolving observational research. This was spurred by the 10-year follow-up of a large randomized Veterans Affairs Hospital trial of medical vs surgical therapy performed in the mid-1980s.[33] Among the medically treated patients, 92% were still on medications, whereas surprisingly 62% of the patients undergoing surgical fundoplication were back on reflux medications (50% proton pump inhibitors [PPIs], 50% histamine-2 receptor antagonists). Furthermore, 16% of the surgical patients had at least 1 additional reflux operation. In a large Veterans Affairs administrative database review of 3145 patients undergoing surgery from 1990–2001 with at least 4.5 years of follow-up, antacid prescriptions were dispensed regularly including histamine-2 receptor antagonists (23.8%), PPIs (34.3%), and prokinetic drugs (9.2%). Overall, nearly 50% of patients received at least 3 prescriptions for one of these drugs.[34] Other surgical centers of excellence studies suggest postoperative rates of use of acid-reducing medications of <20%.[1]

Does the fact that the patient is back on PPIs prove that surgery has failed? This can only be accurately assessed with postoperative pH testing in symptomatic patients. Two studies have adequately addressed this issue, with similar findings. Lord et al[35] identified 37 patients (43%) who were taking acid suppression medications after fundoplication. However, only 24% (9 of 37) had abnormal 24-hour pH testing. Recurrent heartburn and regurgitation were the only symptoms associated with abnormal pH results. Likewise, Wijnhoven et al[36] identified by postal survey 312 patients (37%) who were taking PPIs an average of 6 years after fundoplication. Postoperative pH studies were abnormal in 16 of 61 patients (26%) on medication and in 5 of 78 patients (6%) not taking medication. Although small studies, these results suggest many patients may be back on medications, not for recurrent acid reflux but for nonspecific peptic symptoms such as dyspepsia or extraesophageal complaints, or they have other reasons for antacid therapy such as peptic ulcer disease. An empirical trial of PPIs is reasonable with recurrent "reflux" symptoms after fundoplication, but the requirement for progressively higher doses of PPIs or possible revision surgery requires documentation that the patient actually has recurrent pathologic acid reflux.

Recurrent Atypical Symptoms. This is a particularly common and important problem. Whereas well-documented heartburn and regurgitation tend to respond to medicine or surgery in 85%–95% of patients,[1,6] pulmonary, ear, nose, and throat, and chest pain, the so-called atypical symptoms of GERD, are less likely to respond to either type of therapy.[37] For example, So et al[38] observed that among 115 patients undergoing laparoscopic fundoplication, 93% had relief of their heartburn, whereas only 56% of 35 patients had relief of atypical symptoms. The response rates for laryngeal, pulmonary, and chest pain symptoms were 78%, 58%, and 48%, respectively. These results are even more disappointing when patients are separated into atypical throat symptoms with classic reflux symptoms or atypical symptom alone. In a recent series, Ratnasingam et al[39] observed that 76% of 61 patients with both typical and atypical reflux symptoms improved after antireflux surgery, whereas only 47% of 23 patients with isolated atypical reflux symptoms had similar improvements after antireflux surgery.

The reasons for these discordant results are poorly understood but are consistent across the literature and independent of surgical skills. Contributing factors include (1) poor understanding of the pathophysiology of these symptoms and relationship to GERD, (2) lack of reliable tests to document GERD as the causal factor for atypical symptoms, (3) poor response of atypical symptoms to even high-dose PPI therapy, and most importantly, (4) the multiple etiologies contributing to these complaints, which often overlap in the same patient.[37] The best predictors of a favorable surgical outcome are the presence of typical heartburn and/or regurgitation, markedly abnormal acid reflux testing (% time pH < 4 more than 12%), and prior improvement of atypical symptoms on PPIs.[38,40] Patients with atypical symptoms not meeting these criteria should be counseled that fundoplication has a high risk of symptomatic failure, surgical side effects may be more common, and alternative explanations for their symptoms should be aggressively pursued.[41]

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