What are the potential complications and management strategies for an adult or child with a history of severe gastroesophageal reflux disease (GERD) who has undergone fundoplication surgery?

Fundoplication Complications

Fundoplication is associated with significant morbidity including postoperative dysphagia (5-43%), gas bloat syndrome, wrap failure requiring revision, and symptom recurrence, with careful patient selection being the most critical factor in preventing these complications. 1

Common Postoperative Complications

Dysphagia

• Postoperative dysphagia affects 5-43% of patients and represents the most frequent complication, occurring more commonly after total (Nissen) fundoplication compared to partial wraps 1
• Mechanisms include a wrap that is too tight, a slipped wrap, or development of paraesophageal hernia 1
• Mild dysphagia occurs in approximately 25% of patients at long-term follow-up, though disturbing symptoms requiring intervention occur in only 16% 2
• Partial fundoplication (270° Toupet) should be strongly considered in patients with impaired esophageal peristalsis to avoid postoperative dysphagia while maintaining reflux control 3, 4

Gas Bloat Syndrome and Related Symptoms

• Gas bloat syndrome occurs when patients cannot belch or vomit effectively due to the fundoplication wrap 1, 3
• Associated symptoms include flatulence (60%), early satiety (51%), meteorism (42%), inability to vomit (27%), and inability to belch (22%) at long-term follow-up 2
• Involuntary burping after fundoplication is most commonly supragastric belching—a behavioral disorder requiring pH/impedance monitoring for diagnosis followed by behavioral therapy, not revisional surgery 5

Wrap Failure and Symptom Recurrence

• Symptom recurrence occurs in up to 30% of cases, with fundoplications often loosening over time, particularly in high-risk populations 6, 7
• Anatomic failures include paraesophageal hernia formation, wrap migration into the mediastinum, and wrap disruption 8, 7
• In pediatric patients, both fundoplication and total esophagogastric dissociation are associated with significant morbidity, though fundoplication offers shorter hospitalization (16 vs 35 days) 9

High-Risk Patient Populations

Pediatric Patients with Special Considerations

• Children with neurologic impairment, esophageal atresia-tracheoesophageal fistula (EA-TEF) repair history, diffuse motility disorders, chronic pulmonary disease, and young infants have significantly higher failure rates 1, 8
• In neurologically impaired children, fundoplication reduces pneumonia rates from 59% to 41% (not statistically significant), while total esophagogastric dissociation reduces rates from 71% to 18% (p=0.006) 9
• For EA-TEF patients with severe refractory GERD and recurrent respiratory illnesses, fundoplication may be necessary when chronic respiratory symptoms are thought secondary to reflux-related aspiration 6

Patients with Impaired Esophageal Motility

• Patients with severely impaired esophageal peristalsis (approximately 20% of GERD patients) should undergo partial rather than total fundoplication to avoid postoperative dysphagia while maintaining reflux control 4
• High-resolution manometry must be performed preoperatively to assess esophageal peristaltic function and guide the choice between total and partial fundoplication 3

Diagnostic Workup for Post-Fundoplication Symptoms

Essential Investigations

• Upper GI endoscopy, manometry, pH studies, and barium swallow should be performed first in patients with persistent dysphagia post-fundoplication to assess wrap integrity and understand the cause 1
• Combined high-resolution esophageal manometry with impedance-pH monitoring definitively diagnoses supragastric belching and excludes structural fundoplication failure 5
• Barium swallow identifies wrap herniation, slippage, or paraesophageal hernia formation 1

Specific Diagnostic Considerations

• 24-hour multichannel intraluminal impedance-pH (MII-pH) monitoring is the gold standard for confirming persistent or recurrent GERD after fundoplication 6
• Endoscopy documents esophagitis, Barrett's esophagus, strictures, or ulceration that may develop post-operatively 6

Management of Failed Fundoplication

Conservative Management Options

• Medical management with proton pump inhibitors may be attempted for mild symptom recurrence 8
• Behavioral therapy targeting unconscious air-swallowing patterns is the primary treatment for supragastric belching, involving biofeedback training and speech therapy techniques 5
• Jejunal feeding using percutaneous tube or Roux-en-Y jejunostomy provides nutritional support when oral intake is compromised 8

Surgical Revision Considerations

• Revision fundoplication requires the same meticulous patient selection, individualization based on anatomy and physiology, and technical precision as the primary operation to optimize success 8
• Balloon dilatation to 30-40 mm should be considered for post-Nissen dysphagia before proceeding to revision surgery 1
• Total esophagogastric dissociation is reserved for severe, refractory cases after failed fundoplication, particularly in neurologically impaired children with persistent pneumonia despite fundoplication 1, 9

Prevention Strategies

Preoperative Patient Selection

• Careful patient selection is the most effective strategy for preventing fundoplication failure 1, 8
• Conditions such as cyclic vomiting, rumination, gastroparesis, and eosinophilic esophagitis must be carefully ruled out before surgery, as they will continue causing symptoms postoperatively 1
• If acid suppression with PPIs is ineffective preoperatively, the accuracy of the GERD diagnosis should be reassessed, as fundoplication may not produce optimal clinical results 1

Preoperative Counseling

• Families must receive adequate counseling and education before the procedure to have a realistic understanding of potential complications, including symptom recurrence 1
• The balance between controlling reflux and avoiding worsening dysphagia from underlying dysmotility must be explicitly discussed, particularly in EA-TEF patients 6

Technical Considerations

• Laparoscopic approach is preferred over open surgery with overall in-hospital mortality of 0.14% 3
• Closure of the diaphragmatic hiatus with non-absorbable sutures is essential to prevent wrap herniation 3
• The wrap should be tension-free to prevent postoperative complications 3

Long-Term Outcomes

Symptom Control

• Despite a 93% rate of mild gastrointestinal symptoms at long-term follow-up, 95% of patients remain completely free of reflux symptoms after laparoscopic Nissen fundoplication 2
• The primary goal in treating GERD surgically is improving quality of life for the patient and family, which must be weighed against the significant complication profile 8

Surveillance Requirements

• Endoscopic surveillance is recommended to monitor healing and detect potential complications 3
• In patients with esophageal substitution or complex anatomy, periodic endoscopic surveillance is advisable to detect potentially malignant lesions 1