Postoperative Gastrointestinal Complaints After
Laparoscopic Nissen Fundoplication
Constantine T. Frantzides, MD, PhD, Mark A. Carlson, MD, John G. Zografakis, MD,
Ronald E. Moore, MD, Tallal Zeni, MD, Atul K. Madan, MD
Objectives: Approximately 80% of patients complain of
various symptoms immediately after laparoscopic Nissen
fundoplication. These symptoms typically are treated
medically without an extensive evaluation to identify the
cause. We reviewed our experience of laparoscopic Nis-
sen fundoplication to determine the course of postopera-
tive symptomatology in our patient population, and
present a rational approach to this problem.
Methods: Over a 10-year period, 628 patients underwent
primary laparoscopic Nissen fundoplication for gastro-
esophageal reflux disease; patients were evaluated with a
standard set of questions for postoperative gastrointestinal
complaints. Three- and 6-month follow-up data were
compared by using the chi square test.
Results: One-year follow-up data were available for 615
patients (98%). All of these patients had symptoms during
the first 3 postoperative months. Early satiety (88%), bloat-
ing/flatulence (64%), and dysphagia (34%) were the most
common; however, 94% of patients had resolution of their
symptoms by the 1-year follow-up visit, and most had
resolved after 3 months. Patients with persistent reflux or
dysphagia after 3 months typically had an anatomic failure
of the operation.
Conclusions: Most patients who have undergone lapa-
roscopic Nissen fundoplication for gastroesophageal re-
flux disease will have gastrointestinal complaints during
the initial 3 postoperative months. Nearly all of these
patients will have resolved their symptomatology after 3
months. Those with persistent symptoms after 3 months
warrant evaluation for operative failure.
Key Words: Gastroesophageal reflux disease, Minimally
invasive surgery, Laparoscopic Nissen fundoplication,
Dysphagia, Postoperative symptoms.
A popular option for the surgical management of gastro-
esophageal reflux disease is minimally invasive Nissen
fundoplication. Similar to that of other “nonamputative”
procedures, the successful outcome of a Nissen fundopli-
cation is dependent on a technically precise operation in
a well-selected patient. Currently, the technical modifica-
tion of Donahue et al (ie, “floppy” fundoplication)1to the
Nissen procedure is in common use, although precise
statistics are not available. The floppy Nissen fundoplica-
tion is favored for the treatment of gastroesophageal re-
flux disease because this procedure maximizes reflux con-
trol while minimizing dysphagia. Minimally invasive
Nissen fundoplication was first described in 1991.2Subse-
quently, the indications, preoperative evaluation, techni-
cal aspects, and outcome for minimally invasive Nissen
fundoplication have been well described.1,3–7
One observation we have made in our own series of
minimally invasive Nissen procedures is the routine
occurrence of temporary postoperative gastrointestinal
complaints (this observation also has been made by
others8–10). We also have observed that many patients are
treated by their referring physicians for these temporary
postoperative gastrointestinal symptoms, perhaps too ag-
gressively, as noted by others.11We therefore wanted to
identify the incidence, severity, and duration of these
symptoms in our patient population to provide prospec-
tive patients with quantitative data on this issue. We found
that the vast majority of postoperative gastrointestinal
Minimally Invasive Surgery Center, Department of Surgery, Evanston Northwestern
Healthcare and Northwestern University, Evanston, Illinois, USA.
(Drs Frantzides, Zeni), Advanced Laparoscopy –Surgery for Northeast Ohio Centers
of Excellence, Akron, Ohio, USA.
(Dr Zografakis), Department of Surgery, Plantation Hospital, Ft. Lauderdale, Flor-
ida, USA (Dr Moore).
Department of Surgery, University of Nebraska Medical Center and the Omaha VA
Medical Center, Omaha, Nebraska, USA (Dr Carlson).
Department of Surgery, University of Tennessee-Memphis, Memphis, Tennessee
USA (Dr Madan).
Presented at the 12thInternational Congress and Endo Expo 2003, SLS Annual
Meeting, Las Vegas, Nevada, USA, September 22–25, 2003.
Address reprint requests to: Constantine T. Frantzides, MD, Professor of Surgery,
Northwestern University, Director, Minimally Invasive Surgery Center, Department
of Surgery, Evanston Northwestern Healthcare, 2650 Ridge Avenue, Burch 106,
Evanston, Illinois 60201, USA. Telephone: 847 570 1422, Fax: 847 733 5018, E-mail:
© 2006 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published by
the Society of Laparoendoscopic Surgeons, Inc.
complaints after minimally invasive Nissen fundoplication
are temporary, and do not require prolonged (if any)
Over a 10-year period, 628 patients underwent laparo-
scopic Nissen fundoplication under the supervision of the
first author (CTF). The typical indication for fundoplica-
tion in this series was gastroesophageal reflux disease; this
diagnosis required objective evidence that usually was in
the form of esophagitis on endoscopy or a positive am-
bulatory pH study, or both.12The technique of “floppy”
Nissen fundoplication has been described.1,13,14The com-
ponents of this procedure that we believe to be critical
include1circumferential esophageal mobilization result-
ing in an adequate length (3 cm to 5 cm) of intraabdomi-
nal esophagus2; closure of the diaphragmatic crura with
posterior (and occasionally anterior) cruroplasty over a
large (56 F to 60 F) bougie3; fundal mobilization with
division of the short gastric vessels4; a short (about 2 cm),
floppy 360° wrap that utilizes the fundus only (not the
gastric body); and5fixation of the wrap to the anterior
crural arch (but not to the esophagus itself). In addition,
we used prosthetic reinforcement of the cruroplasty when
faced with a large hiatal defect; this practice reduced hiatal
hernia recurrence in a randomized trial.15
Postoperative follow-up was performed in the office of
the supervising surgeon at 1 week, then at 1, 3, and 6
months, and then yearly. Postfundoplication dietary re-
strictions included avoidance of carbonated beverages
and gas-producing food for 3 months, and eliminating
meat for 1 month after surgery. In general, the patients
had no dietary restrictions after 3 months. At each fol-
low-up visit, each patient was queried regarding early
satiety, dysphagia, odynophagia, hiccups, diarrhea, nau-
sea, bloating/flatulence, and constipation (Table 1). The
incidence of each symptom during different postoperative
periods was compared with the Fischer exact or chi
square test; the level of significance was P?0.05.
Twelve-month follow-up data were available in 615/628
patients (98%). Recurrent reflux (ie, a failed procedure)
occurred in 16 patients (2.5%); in 14 of these, the failure of
the procedure was evident by the 6-month follow-up visit.
Exclusion of the above 16 patients (ie, those with reflux
recurrent at ?3 months postoperatively) left 599 patients
for analysis. During the first 3 postoperative months, 100%
of these patients had at least 1 gastrointestinal complaint;
early satiety (88%), bloating/flatulence (64%), and dys-
phagia (34%) were the most common symptoms (Table
2). The vast majority of these symptoms were resolved
Questions Administered at Each Follow-up Visit12
1. Do you have difficulty swallowing? If so, does the
difficulty seem to be in the upper or lower chest? Is the
difficulty with solids or liquids or both?
2. Do you experience heartburn? How often?
3. Do you experience pain with swallowing?
4. Do you experience chest pain when swallowing?
5. Do you vomit? How often?
6. Do you experience nausea?
7. Do you have dry heaves, hiccups, or both?
8. Do you regurgitate liquids, solids, or both?
9. Do you have a morning cough?
10. Do you have difficulty breathing or asthma?
11. Do you have voice hoarseness?
12. Do you have bloating, or flatulence (gas from below), or
13. Do you get full with small portions of food?
14. Do you have diarrhea? How often?
15. Do you have constipation?
16. Do you have indigestion? How often?
Gastrointestinal Symptoms 0 to 3 and 3 to 12 Months After
Minimally Invasive Nissen Fundoplication*
SymptomNumber of Patients With
Symptom During Indicated
*Comparison of the incidence between the 2 periods was per-
formed with either the Fisher exact or chi square test.
Postoperative Gastrointestinal Complaints After Laparoscopic Nissen Fundoplication, Frantzides CT et al
within the first 4 weeks to 6 weeks after the procedure
(data on the precise time of symptom resolution are not
available). In the 3-month to 12-month postoperative in-
terval, the incidence of gastrointestinal complaints in the
599 patients decreased markedly; specifically, 94% of
these patients did not report symptoms during this period
The symptoms of bloating and flatulence (n ? 21), dys-
phagia,5and diarrhea7were persistent in 33 patients be-
yond the third postoperative month (Table 2). Of note, 5
patients with persistent flatulence or diarrhea carried a
preoperative diagnosis of irritable bowel syndrome. Up-
per endoscopy and barium radiography were performed
in the 5 patients with persistent postoperative dysphagia;
the associated causes included a slipped fundoplication
(n?2), and a tight cruroplasty, a tight wrap, and no iden-
tifiable cause (n?1 each). Eleven patients with bloating
and flatulence and 4 patients with diarrhea were evaluated
with upper endoscopy, colonoscopy, and Clostridium dif-
ficile testing; none of this evaluation identified causative
Up to 62% of patients who have undergone an antireflux
procedure may be treated chronically with antireflux med-
ication in the postoperative period16; such postoperative
antireflux treatment is given in some cases without docu-
mentation of reflux.17We have documented a high inci-
dence (100% of our series) of temporary postoperative
gastrointestinal complaints after laparoscopic Nissen fun-
doplication. Other authors also have observed similar
rates of temporary complaints after an antireflux proce-
dure.6,18It has been our experience that these postoper-
ative gastrointestinal complaints resolve by 3 months in
over 90% of the patients. Interestingly, it has been shown
that the accuracy of postoperative symptoms in predicting
objective reflux (as measured by 24-hr pH monitoring) is
poor, and that some asymptomatic patients actually may
have subclinical reflux after a “successful” fundoplica-
tion.11We would argue that the more relevant observation
is that laparoscopic antireflux surgery, when performed
by experienced surgeons, results in a long-term clinical
success rate of 90%.4,5
Postoperative symptoms like bloating, flatulence, and dys-
phagia can be minimized with the avoidance of carbon-
ated beverages, gas-producing foods (eg, beans), and
coarse substances (eg, red meat). Patients may still have
the sensation of heartburn after a successful antireflux
procedure. This is not necessarily indicative of recurrent
reflux, but possibly due to irritation of the esophageal
mucosa secondary to drinking a relatively caustic bever-
age, such as citrus juice or alcohol. These beverages also
should be avoided for several months so that the patient’s
esophagitis has a chance to resolve. If gastrointestinal
symptoms occur during the first 3 months after fundopli-
cation, our evidence suggests that the symptoms resolve
in the vast majority of patients. Chronic medication is not
required. The only treatment needed at this point is pa-
tient education and reassurance. If a patient has symptoms
that persist beyond the 3 months postoperatively, how-
ever, an endoscopic and contrast fluoroscopic evaluation
should be undertaken.
Other than recurrent reflux, the most common persistent
symptom requiring intervention in our series was dyspha-
gia, which happened in 1% of our patients. The cause of
postoperative dysphagia is multifactorial,10including fac-
tors such as an undiagnosed motility disorder (eg, acha-
lasia), a wrap failure (eg, slippage, overly tight wrap or
cruroplasty, or corpus wrap), retroperitoneal hematoma,
or peptic stricture. Treatment for dysphagia is specific to
its cause, such as revisional surgery for wrap failure.19–22
Persistent bloating/flatulence may be treated with sime-
thicone and dietary modification; further treatment can
consist of speech therapy to retrain/control swallowing
frequency.23The cause of persistent diarrhea often is not
clear; vagal injury often is implicated.24The treatment of
persistent diarrhea includes antidiarrheals; further evalu-
ation of the lower gastrointestinal tract (for irritable bowel
syndrome, pseudomembranous colitis, etc) might be con-
Since 1995 laparoscopic Nissen fundoplication has been
shown to be safe and effective therapy for gastroesopha-
geal reflux disease. Although many patients will have
gastrointestinal complaints during the first 3 months after
laparoscopic Nissen fundoplication, the vast majority of
these symptoms will resolve and do not require chronic
treatment. We suggest patient education and reassurance
for the complaints that come up during this initial period,
and reserve further evaluation for symptoms that persist
beyond 3 months.
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