Resolution of
heartburn
Resolution of extraesophageal symptoms
Group 1 – Severe heartburn/Minimal extraesophageal symptoms
87%
–
Group 2 – Severe heartburn/Severe extraesophageal symptoms
76%
42%
Group 3 – Minimal heartburn/Severe extraesophageal symptoms
–
48%
During preoperative evaluation, the surgeon should mandate anatomic and physiologic testing to prove the presence of GERD, and should carefully counsel patients about the likelihood of responsiveness for all symptoms present. A low correlation between extra-esophageal symptoms and reflux episodes on pH-impedance testing has been shown to predict poor responsiveness of these symptoms after antireflux surgery [7].
Objective evidence of GERD is needed before a surgeon offers antireflux surgery. This may include significant mucosal manifestations in the setting of esophageal symptoms (ulcerative esophagitis, Barrett’s esophagus, peptic stricture) or abnormalities in pH or impedance testing [8]. In addition, many experts advocate for routine esophageal manometry testing to rule out unrecognized esophageal motility disorders, since approximately 30% of patients with GERD will have ineffective esophageal motility due to low-amplitude waves or simultaneous contractions [9]. Awareness of the manometric profile allows tailoring of the degree of fundoplication for the purpose of reducing postoperative dysphagia, although this has been a highly debated topic since the inception of laparoscopic antireflux surgery 25 years ago. Currently, a 360° floppy Nissen fundoplication is the recommended treatment for patients with GERD, with reservation of a partial fundoplication for patients with achalasia and scleroderma. This practice has been supported by many studies [10–13]. A recent meta-analysis showed that Nissen fundoplication was associated with significantly more dysphagia compared to Toupet fundoplication, affecting 80/637 (12.56%) and 30/620 (4.84%) respectively [14]. There is significant heterogeneity in how dysphagia is quantified; authors may rely on visual analogue scale or questionnaire, and fail to stratify data for solids and liquids [15]. Gastric emptying studies have been examined to potentially identify patients at risk for significant nausea, bloating and gassiness after antireflux surgery, but there are no data to support correlation between results and postoperative outcomes. Gastric emptying studies may be helpful in patients with new or persistent symptoms following fundoplication, as it provides indirect evidence for vagal nerve injury during the index operation [2, 16, 17].
Common Postoperative Symptoms
Approximately 80% of patients experience new symptoms after antireflux surgery [18, 19]. Often these symptoms include “gas-bloat syndrome” and dysphagia. These are generally attributed to the inflammation that exists after an operative intervention and the presence of an intact fundoplication.
Gas-bloat syndrome is associated with the reduced ability to belch after fundoplication. It affects up to 85% of patients after surgery, and usually includes early postoperative bloating, flatulence and abdominal distention that improves over the weeks to months after operation [20]. Gas-bloat syndrome may also be associated with early satiety, nausea, and abdominal pain. These symptoms may become especially prominent in patients with a habit of aerophagia or with delayed gastric emptying, whether pre-existing or related to unintended vagotomy [21]. Temporary avoidance of carbonated beverages and the use of simethicone or prokinetic drugs will usually temper the gas-bloat symptoms. In rare cases, a venting gastrostomy, endoscopic dilation, conversion to a partial fundoplication or a pyloroplasty may be necessary [22].
Dysphagia is expected in all patients for the first 2–3 months after operation, presumably due to postoperative edema which affects bolus transit. Patients with preexisting esophageal dysmotility may have more significant postoperative dysphagia, but by 3 months, there is no statistical difference [9, 23]. Dietary modifications and time are usually all that is needed. In 3–12%, persistent dysphagia may require endoscopic dilation. In some cases, such as a too-tight or slipped fundoplication or motility disorder, surgical revision is necessary [24].
Postoperative diarrhea is a frequent occurrence after fundoplication, affecting 18–33% of patients [25, 26] It usually develops within 6 weeks of operation and is typically mild and of low volume and frequency, occurring after meals. Mechanisms may include accelerated gastric emptying after fundoplication with dumping syndrome, or vagal injury with subsequent small bowel overgrowth [25]. Management is empirical [18].
Flatulence has been reported in 12%–88% of patients after antireflux surgery [26, 27]. This is a downstream effect of gas-bloat syndrome during the recovery phase when patients have limited ability to belch. It can be treated with Simethicone and speech therapy.
Most of the expected symptoms after fundoplication are transient, and therefore they do not mandate an extensive evaluation. In one study of postoperative symptoms, 94% were resolved by 1 year, with most abating within the first 3 months [19].
Unexpected Postoperative Symptoms
In some situations, persistent or recurrent esophageal symptoms may occur after antireflux surgery and raise suspicion for a failing fundoplication. In fact, acid suppressive medications are resumed in up to 62% of patients after antireflux surgery [28, 29], with most studies reporting <20% [2]. However, studies of patients who resume medications show only 24–37% actually have pH-metric evidence of recurrent GERD [30–33]. Therefore, while it may be reasonable to use PPIs empirically at first, it is not appropriate to escalate medication utilization or consider antireflux surgery without objective evidence of associated pathologic reflux [18].
Esophageal and extra-esophageal symptoms after antireflux surgery may also be attributable to esophageal hypersensitivity, eosinophilic esophagitis, and non-specific spastic esophageal motor disorders.
Esophageal hypersensitivity refers to heightened esophageal symptom perception. Patients may suffer more dramatic symptoms of GERD, and can also sense non-GERD related mechanical or chemical stimuli, such as distension of the esophagus from refluxed or swallowed air, as GERD. These patients may have high correlation indices but normal acid exposure on pH monitoring. GERD may contribute to the etiology, and GERD therapy may improve esophageal sensitivity. However, esophageal hypersensitivity may also exist without GERD, and can sometimes raise suspicion for failed antireflux surgery. Beyond traditional antireflux therapies, inhibitors of transient lower esophageal sphincter relaxation, such as baclofen, and neuromodulators, such as low-dose antidepressants, may suppress symptoms [34].
A small percentage of patients who carry the diagnosis of refractory GERD actually have eosinophilic esophagitis (EoE) [35], which is a chronic allergic condition of the esophagus. The diagnosis requires a high index of suspicion, and is confirmed by proximal and distal esophageal biopsies which demonstrate eosinophilia. The diagnosis requires esophageal biopsies demonstrating at least 15 eosinophils per high-powered field in the setting of appropriate antireflux therapy [36]. In a post-fundoplication patient, anatomic and physiologic studies will support an intact fundoplication. Once diagnosed, treatment involves avoidance of food allergens, steroidal anti-inflammatory medications and dilation(s) of the esophagus [37].
This endoscopic image shows esophageal rings, mild narrowing, white plaques/exudates, edema/loss of vascularity, and linear furrows (Courtesy of E Dellon, UNC 2016 [38])
Incomplete preoperative evaluation may result in esophageal symptoms after surgery. For example, unrecognized motility disorders, such as achalasia, can contribute to GERD-like symptoms due to esophageal stasis [39]. Postoperative symptoms may incorrectly be attributed to a failure of antireflux surgery when the true issue is an unrecognized motility disturbance. Morais et al. identified 41 patients with persistent postoperative dysphagia, defined as dysphagia greater than 6 months following initial operation. They were evaluated with endoscopy, barium swallow, and esophageal manometry, and compared to 19 controls, also greater than 6 months out from Nissen fundoplication, without dysphagia. Half of the symptomatic group had normal manometry, but the other half had evidence of esophageal dysmotility [40]. Preoperative testing was not performed, highlighting the need for thorough preoperative evaluation.
It is imperative to complete a full diagnostic evaluation including upper endoscopy, barium swallow, pH testing and esophageal manometry when evaluating post-fundoplication symptoms. Nuclear medicine gastric emptying study should be considered, as well.
Persistent extra-esophageal symptoms may also be prominent in the postoperative phase. This may be reflective of a non-GERD etiology. Response rates for laryngeal, pulmonary, and chest pain symptoms have been reported as 78%, 58% and 48%, respectively, highlighting that improvement in these symptoms cannot be guaranteed after antireflux surgery [41]. Thorough pulmonary and upper respiratory evaluation should be considered in symptoms that persist or develop.
GERD has emerged as a comorbidity of chronic obstructive pulmonary disease (COPD) with prevalence ranges from 17% to 78%, and there is significant overlap in symptoms of these two common diseases. GERD has been identified as a significant predictor of acute exacerbations of COPD [42].
Some patients and surgeons may have concern that downstream functional gastrointestinal conditions, such as irritable bowel syndrome (IBS), will be “unmasked” by antireflux surgery. There is certainly a significant amount of overlap between symptoms associated with GERD and IBS. While there needs to be a discussion that certain symptoms may become more prominent, available data support that fundoplication is associated with reduction of IBS symptoms below the Rome II criteria in 80.6% of patients with a preoperative IBS diagnosis [43]. The emersion of IBS symptoms has not been extensively studied, although patients have been identified that were evaluated preoperatively with normal Rome II criteria that transitioned to positive IBS criteria postoperatively.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
