Complications of Surgery for Gastroesophageal Reflux

Key Points

• Anti-reflux surgery is an effective alternative to medical therapy with strong evidence supporting improved quality of life.
• It is impossible to avoid all intraoperative complications but they can be significantly decreased by applying sound surgical principles and careful dissection around the hiatus, vagal nerves and vascular structures.
• Early postoperative nausea, emesis and belching are stressors that can lead to early recurrence and disruption of the wrap. If suspected, early constrast esophagograms should be utilized for diagnosis.
• It is crucial to understand the causes of fundoplication failure in order to best prevent wrap migration. Intraoperative measures including adequate reduction of diaphragmatic tension and crural closure, reduction of axial tension along the esophagus, and proper construction of the wrap are paramount to reduce post-operative migration.
• Laparoscopic anti-reflux surgery is complicated and requires proper training and preparation in order to minimize patient complications. In addition, careful patient selection and counseling are crucial in order to manage expectations and optimize post-operative success.

Antireflux surgery is an indispensible tool in the armamentarium of the thoracic surgeon who treats gastroesophageal reflux disease (GERD). The long-term efficacy of antireflux surgery has been shown to be at least as effective, if not more effective, than medical management of GERD.[1][2][3][4][5][6] Furthermore, surgery offers higher long-term quality of life scores and higher patient satisfaction rates, with long-term cost-effectiveness trending towards fundoplication when compared to medical therapy.[1][2][7][8][9][10] Although antireflux surgery is not without its share of unwanted side-effects, recent reports have brought to light significant side-effects associated with long-term proton-pump inhibitor use including increased risk of chronic kidney disease, dementia, and cardiovascular events.[11][12][13] With one-quarter of the population experiencing weekly symptoms of GERD and the excellent outcomes from surgery it is surprising to see that less than 1% of patients ever receive operative intervention.[14][15] There are multiple reasons for this but many patients and referring physicians perceive anti-reflux surgery as invasive, ineffective and complicated.

It is impossible to avoid all complications related to antireflux surgery. However, they can be minimized with proper patient selection and counseling in addition to the application of sound surgical technique and post-operative management. While the laparoscopic approach is the most frequently utilized antireflux procedure, other modalities including implantable devices, novel endoscopic therapies and the traditional thoracic approach are all being performed. The definition of a complication for this operation can range from immediate complications that occur at the time of the operation to early postoperative complications that reduce the function of the procedure or introduce unwanted side effects.

This chapter attempts to describe the most commonly encountered complications of antireflux surgery as well as provides the knowledge to help avoid and manage them with a focus on the following:

• Intraoperative Complications
• Early Postoperative Complications
• Late Postoperative Complications