Causes of Vomiting After Nissen Fundoplication
The most common causes of vomiting after Nissen fundoplication include mechanical complications such as a tight wrap, slipped wrap, or paraesophageal hernia, as well as functional issues like delayed gastric emptying and dumping syndrome. 1
Mechanical Complications
Wrap-Related Issues
- Tight wrap: A fundoplication that is too tight can cause obstruction at the gastroesophageal junction, leading to vomiting and inability to tolerate oral intake
- Slipped wrap: When the wrap migrates distally, it can create a partial or complete obstruction
- Disrupted wrap: Partial or complete breakdown of the fundoplication can lead to recurrent reflux symptoms including vomiting
Herniation Issues
- Paraesophageal hernia: Occurs in 5-43% of post-fundoplication patients 1
- Hiatal hernia recurrence: Can range from small to large (Type IV) hernias where stomach and even colon can herniate into the chest 2
- Wrap herniation: The entire wrap can migrate into the chest through the hiatus
Functional Complications
Gastric Motility Disorders
- Delayed gastric emptying: Common after fundoplication and can cause persistent vomiting 1
- May require specific treatment to reduce the need for redilatations
- Often pre-exists but becomes symptomatic after surgery
Post-Fundoplication Syndromes
- Gas-bloat syndrome: Inability to belch leads to gastric distention, nausea and vomiting 3, 4
- Dumping syndrome: Reported in patients after Nissen fundoplication 1
- Early dumping (within 1 hour): Abdominal pain, bloating, nausea, vomiting
- Late dumping (1-3 hours): Hypoglycemia-related symptoms
Diagnostic Approach
Initial Evaluation
- Upper GI endoscopy: To assess the integrity of the wrap and identify complications such as strictures or esophagitis 1
- Barium swallow: Essential to identify anatomical abnormalities such as hiatal hernia, slipped wrap, or obstruction 1
- Manometry: To evaluate esophageal motility and lower esophageal sphincter function 1
- pH/impedance monitoring: To objectively confirm or reject persistent gastroesophageal reflux 1
Key Findings to Look For
- Endoscopic evidence of a tight, slipped, or disrupted wrap
- Radiographic evidence of obstruction or herniation
- Abnormal esophageal motility patterns
- Delayed gastric emptying on scintigraphy (if performed)
Management Strategies
Conservative Management
- Dietary modifications: Small, frequent meals low in carbohydrates
- Prokinetic medications: For delayed gastric emptying
- Proton pump inhibitors: If reflux persists or recurs
Endoscopic Interventions
- Balloon dilatation: Consider for post-Nissen dysphagia (30-40 mm balloons) 1
- Endoscopic evaluation: Important before considering surgical revision
Surgical Revision
- Indications: Persistent symptoms despite conservative management, anatomical abnormalities requiring correction
- Approach: Laparoscopic approach is feasible and safe for revisional surgery 1
- Options:
- Conversion to partial fundoplication (Toupet) if dysphagia is predominant
- Repair of hiatal hernia with non-absorbable sutures
- Redo fundoplication with proper technique
Prevention and Follow-up
Preventive Measures
- Proper patient selection for initial fundoplication
- Appropriate surgical technique with adequate mobilization
- Closure of the crura with non-absorbable sutures
- Avoiding excessive tightness of the wrap
Long-term Follow-up
- Regular clinical assessment for recurrent symptoms
- Endoscopic surveillance if Barrett's esophagus was present
- pH/impedance monitoring for persistent symptoms to guide management 1
Common Pitfalls
- Assuming all post-fundoplication vomiting is due to recurrent reflux
- Failing to distinguish between mechanical and functional causes
- Overlooking delayed gastric emptying as a contributing factor
- Not performing complete diagnostic workup before revisional surgery
- Treating symptoms with medications without identifying the underlying anatomical problem
Remember that post-Nissen fundoplication vomiting requires thorough evaluation to identify the specific cause before determining the appropriate management strategy.