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a popular option for the surgical management of gastroesophageal reflux disease is minimally invasive nissen fundoplication .
similar to that of other  nonamputative  procedures , the successful outcome of a nissen fundoplication is dependent on a technically precise operation in a well - selected patient .
floppy  fundoplication ) to the nissen procedure is in common use , although precise statistics are not available .
the floppy nissen fundoplication is favored for the treatment of gastroesophageal re - flux disease because this procedure maximizes reflux control while minimizing dysphagia .
subsequently , the indications , preoperative evaluation , technical aspects , and outcome for minimally invasive nissen fundoplication have been well described .
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 others ) .
we also have observed that many patients are treated by their referring physicians for these temporary postoperative gastrointestinal symptoms , perhaps too aggressively , as noted by others .
we therefore wanted to identify the incidence , severity , and duration of these symptoms in our patient population to provide prospective patients with quantitative data on this issue .
we found that the vast majority of postoperative gastrointestinal complaints after minimally invasive nissen fundoplication are temporary , and do not require prolonged ( if any ) medical treatment .
over a 10-year period , 628 patients underwent laparoscopic nissen fundoplication under the supervision of the first author ( ctf ) .
the typical indication for fundoplication 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 ambulatory ph study , or both .
the components of this procedure that we believe to be critical include circumferential esophageal mobilization resulting in an adequate length ( 3 cm to 5 cm ) of intraabdominal esophagus ; closure of the diaphragmatic crura with posterior ( and occasionally anterior ) cruroplasty over a large ( 56 f to 60 f ) bougie ; fundal mobilization with division of the short gastric vessels ; a short ( about 2 cm ) , floppy 360 wrap that utilizes the fundus only ( not the gastric body ) ; and fixation 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 .
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 restrictions included avoidance of carbonated beverages and gas - producing food for 3 months , and eliminating meat for 1 month after surgery .
each follow - up visit , each patient was queried regarding early satiety , dysphagia , odynophagia , hiccups , diarrhea , nausea , 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 .
if so , does the difficulty seem to be in the upper or lower chest ? is the difficulty with solids or liquids or both ?
do you have bloating , or flatulence ( gas from below ) , or both ?
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 dysphagia ( 34% ) were the most common symptoms ( table 2 ) .
the vast majority of these symptoms were resolved 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 interval ,
the incidence of gastrointestinal complaints in the 599 patients decreased markedly ; specifically , 94% of these patients did not report symptoms during this period ( table 2 ) .
gastrointestinal symptoms 0 to 3 and 3 to 12 months after minimally invasive nissen fundoplication * comparison of the incidence between the 2 periods was performed with either the fisher exact or chi square test .
the symptoms of bloating and flatulence ( n = 21 ) , dysphagia , and diarrhea were persistent in 33 patients beyond the third postoperative month ( table 2 ) .
of note , 5 patients with persistent flatulence or diarrhea carried a preoperative diagnosis of irritable bowel syndrome .
upper 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 identifiable cause ( n=1 each ) .
eleven patients with bloating and flatulence and 4 patients with diarrhea were evaluated with upper endoscopy , colonoscopy , and clostridium difficile testing ; none of this evaluation identified causative pathology .
up to 62% of patients who have undergone an antireflux procedure may be treated chronically with antireflux medication in the postoperative period ; such postoperative antireflux treatment is given in some cases without documentation of reflux .
we have documented a high incidence ( 100% of our series ) of temporary postoperative gastrointestinal complaints after laparoscopic nissen fundoplication .
it has been our experience that these postoperative 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
we 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% .
postoperative symptoms like bloating , flatulence , and dysphagia can be minimized with the avoidance of carbonated beverages , gas - producing foods ( eg , beans ) , and coarse substances ( eg , red meat ) .
this is not necessarily indicative of recurrent reflux , but possibly due to irritation of the esophageal mucosa secondary to drinking a relatively caustic beverage , 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 fundoplication , our evidence suggests that the symptoms resolve in the vast majority of patients .
the only treatment needed at this point is patient education and reassurance . if a patient has symptoms that persist beyond the 3 months postoperatively , however , an endoscopic and contrast fluoroscopic evaluation should be undertaken .
other than recurrent reflux , the most common persistent symptom requiring intervention in our series was dysphagia , which happened in 1% of our patients .
the cause of postoperative dysphagia is multifactorial , including factors such as an undiagnosed motility disorder ( eg , achalasia ) , 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 .
persistent bloating / flatulence may be treated with simethicone and dietary modification ; further treatment can consist of speech therapy to retrain / control swallowing frequency .
the cause of persistent diarrhea often is not clear ; vagal injury often is implicated .
the treatment of persistent diarrhea includes antidiarrheals ; further evaluation of the lower gastrointestinal tract ( for irritable bowel syndrome , pseudomembranous colitis , etc ) might be considered .
since 1995 laparoscopic nissen fundoplication has been shown to be safe and effective therapy for gastroesophageal 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 .
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 nissen fundoplication to determine the course of postoperative 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 gastroesophageal 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% ) , bloating / 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 laparoscopic 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 .