Management of Involuntary Burping After Nissen Fundoplication
The involuntary burping you're experiencing after Nissen fundoplication is most likely supragastric belching—a behavioral disorder where you're unconsciously swallowing air and immediately expelling it from the esophagus without it reaching the stomach—and this requires pH/impedance monitoring for diagnosis followed by behavioral therapy rather than additional surgery. 1
Understanding What's Happening
After fundoplication, your body's normal belching mechanism has been fundamentally altered. The surgery successfully prevents gastric belching (air venting from the stomach) by creating a tight wrap around the lower esophagus, but this triggers a compensatory increase in supragastric belching as your body futilely attempts to vent air that it perceives is trapped in the stomach. 1 This explains why up to 22-27% of post-fundoplication patients report inability to belch normally, yet paradoxically many experience increased belching frequency. 2, 3
The key distinction: true gastric belching after fundoplication is nearly impossible due to the surgical wrap preventing transient lower esophageal sphincter relaxation, so what you're experiencing is air being sucked into the esophagus through upper esophageal sphincter relaxation and immediately expelled—never reaching your stomach at all. 4
Diagnostic Workup Required
You need combined high-resolution esophageal manometry with impedance-pH monitoring to definitively diagnose supragastric belching and exclude other causes. 1 This testing will:
- Differentiate supragastric belching from the rare persistent gastric belching or non-acid reflux 1
- Document that air flows into the esophagus through upper esophageal sphincter relaxation before any lower esophageal activity (the hallmark of supragastric belching) 1
- Exclude structural fundoplication failure or recurrent reflux as the cause of your symptoms 1
The British Society of Gastroenterology specifically recommends pH/impedance monitoring (not pH alone) for persistent symptoms after fundoplication because it can objectively confirm or exclude persistent reflux and identify supragastric belching as the culprit. 1
Treatment Approach
First-Line: Behavioral Therapy
Behavioral therapy targeting the unconscious air-swallowing pattern is the primary treatment for supragastric belching. 1 This involves:
- Biofeedback training using visual feedback from impedance monitoring to help you recognize and suppress the belching behavior 1
- Speech therapy techniques to reduce air swallowing 1
- Cognitive-behavioral approaches if anxiety is a contributing factor (supragastric belching is strongly associated with anxiety) 1
What NOT to Do
Avoid revisional surgery as a first approach—the belching is not due to surgical failure but rather a behavioral adaptation to the altered anatomy. 1 Manometric studies show that post-fundoplication patients have zero transient lower esophageal sphincter relaxations during gastric distension (compared to healthy controls who have multiple), confirming the wrap is functioning correctly even when patients report severe belching. 4
Common Pitfall to Avoid
Do not assume your belching represents fundoplication failure or that you need reoperation without objective testing. 1 Studies show poor correlation between postoperative reflux symptoms and actual gastroesophageal reflux—68% of patients taking acid-reducing medications after fundoplication had completely normal reflux monitoring. 1 Your subjective reporting of belching ability is likely inaccurate; manometric measurement provides the objective assessment needed. 4
Expected Outcomes
While 93% of post-fundoplication patients experience some gastrointestinal symptoms (including inability to belch in 22%), only 16% find these symptoms truly disturbing, and 95% remain completely free of reflux symptoms with high overall satisfaction. 2 The mild side effects (postprandial fullness, early satiety, flatulence) are typically transitory and well-tolerated long-term. 3
Your fundoplication is likely working exactly as intended—controlling reflux—but has triggered this compensatory behavioral response that requires behavioral intervention rather than surgical revision. 1, 4