What are the adverse effects of Nissen fundoplication?

Adverse Effects of Nissen Fundoplication

Nissen fundoplication is associated with several significant adverse effects, with dysphagia occurring in 6-17% of patients and gas bloat syndrome in approximately 13% of patients, while perioperative mortality is very low at less than 1%. 1, 2

Common Adverse Effects

Immediate Post-Operative Complications

• Perioperative morbidity: Occurs in approximately 14% of patients 1
• Perioperative mortality: Very low (less than 1%) 1
• Intraoperative complications: Can include bleeding, liver and spleen capsule tears, and stomach perforation (18% in non-transplant patients) 1

Short to Medium-Term Complications

• Dysphagia:

  • Occurs in 6-17% of patients 1, 2
  • May require endoscopic dilatation in approximately 2% of cases 2
  • Can be severe enough to require reoperation in some cases 3

• Gas bloat syndrome:

  • Affects approximately 13% of patients 2
  • Characterized by inability to belch, abdominal distention, and flatulence
  • May be exacerbated by underlying lactose intolerance 4

• Inability to vomit: Common after tight fundoplication wraps 3

Long-Term Complications

• Recurrent reflux: Occurs in 5-17% of patients 3, 2

  • May require revision surgery in approximately 5% of cases 2

• Paraesophageal hernia: Occurs in 5-43% of post-fundoplication patients 5

• Slipped wrap: When the fundoplication migrates upward, causing recurrent symptoms 6

• Dumping syndrome:

  • Rapid gastric emptying causing both gastrointestinal and vasomotor symptoms
  • Can occur following Nissen fundoplication, especially in adults 7

• Delayed gastric emptying 5

Risk Factors for Complications

1. Technical factors:

   • Wrap that is too tight or too loose
   • Incorrect positioning of the wrap
   • Inadequate mobilization of the fundus

2. Patient factors:

   • Pre-existing esophageal dysmotility
   • Poor patient selection
   • Lack of response to PPI therapy before surgery 5

Special Considerations

In lung transplant recipients with gastroesophageal reflux:

• Perioperative complications may be higher than in non-transplant patients
• Longer post-operative hospital stay (2.9 versus 0.7 days)
• Higher 30-day readmission rate (25% versus 3.2%) 1

However, fundoplication may improve lung function in these patients when they have confirmed gastroesophageal reflux 5.

Prevention of Complications

1. Proper patient selection:

   • Confirm GERD diagnosis with objective testing
   • Select patients who previously responded to PPI therapy 5
   • Identify patients with high acid exposure time (>12%) 5

2. Surgical technique:

   • Avoid creating a wrap that is too tight
   • Ensure proper positioning of the wrap
   • Adequate mobilization of the fundus

3. Post-operative follow-up:

   • Endoscopy at 2-3 months post-surgery
   • Annual esophagogram
   • Prompt evaluation of recurrent symptoms 5

When performed in a standardized way by experienced surgeons, Nissen fundoplication has a success rate of 80-90% for symptom relief in properly selected patients 5, 2, with persistent dysphagia being relatively rare at 2% in recent studies 2.