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THE IMPACT OF GAS BLOAT SYNDROME ON OUTCOMES AFTER NISSEN FUNDOPLICATION AND ITS ASSOCIATION WITH ANATOMICAL FAILURE AND NEED FOR REVISIONAL SURGERY
Inanc Sarici
*1,3, Sven Eriksson
1,3, Johnathan Nguyen
1, Naveed Chaudhry
1, Ping Zheng
1, Shahin Ayazi
1,2,31Foregut Division, Surgical Institute, Allegheny Health Network, Pittsburgh, PA; 2Department of Surgery, Drexel University, Philadelphia, PA; 3Chevalier Jackson Research Fellowship, Esophageal Institute, Western Pennsylvania Hospital, Allegheny Health Network, Pittsburgh, PA
Introduction: Gas bloat syndrome (GBS) is a common complication following Nissen fundoplication likely resulting from an inability to vent gastric distension. There is concern that GBS may negatively impact the integrity of the antireflux barrier, leading to diminished quality of life and increased risk of anatomic failure. However, the relationship between GBS and the incidence of failure and need for revisional surgery is not well established. This study aims to assess the impact of GBS on the outcome after Nissen fundoplication, incidence and onset of anatomical failure and need for revisional surgery.
Methods: Records of patients who underwent primary Nissen fundoplication at our institution were reviewed. Those who completed GERD-Health-Related Quality of Life (GERD-HRQL) questionnaire post-surgery were selected. Patients were categorized based on GBS, defined as a score ?4 on the gas-bloat specific item of the GERD-HRQL questionnaire. Anatomical failure was defined as recurrent hiatal hernia or fundoplication disruption on endoscopy. Demographic, preoperative clinical, outcome and failure data were compared between patients with and without GBS.
Results: The final study population consisted of 554 patients (70.6% female) with a median (IQR) age of 61 (51-69) and BMI of 29 (25-32). At a mean (SD) of 14.6 (8) months 137 patients (24.7%) had GBS (
Table). These patients were younger [59 (47-68) vs. 63 (52-69), p=0.020] and more often female (79.6% vs. 67.6%, p=0.0093). They also had a higher preoperative GERD-HRQL score [40 (27-54) vs. 30 (14-48), p=0.0006] with more severe gas-bloat symptoms (55.9% vs. 28.7%, p<0.0001). There was no difference in BMI, hernia size >3 cm, and LA grade C/D esophagitis between groups (p>0.05). Postoperatively, the GBS group had a higher GERD-HRQL total score [14 (8-29) vs. 5 (2-12), p<0.0001], PPI-use (21.2% vs. 9.8%, p=0.002), dissatisfaction (38.0% vs. 12.9%, p<0.001) and the rate of esophagitis (10.9% vs. 5.5%, p=0.049).
Anatomical failure developed in 53.3% of patients with GBS and 18.0% of patients without GBS (p<0.0001). The median (IQR) time to anatomical failure was significantly shorter in the GBS group [22 (12-32) months vs. 32 (15-46) months, p=0.0039] (
Figure). The need for revisional ARS was also higher in the GBS group (28.5% vs. 8.4%, p<0.0001).
Conclusion: Gas bloat syndrome following Nissen fundoplication had a markedly detrimental impact on postoperative quality of life and satisfaction with outcome. Additionally, patients with severe GBS were more likely to develop anatomical failure and had a shorter onset of failure than those without GBS. These findings suggest that GBS is an important factor influencing long-term outcomes after Nissen fundoplication, highlighting the need for closer monitoring.
Kaplan-Meier curve comparing time to endoscopic detection of anatomical failure after antireflux surgery between patients with postoperative gas-bloat syndrome (red) and patients without (blue), which was significantly shorter in patients with gas-bloat syndrome (p<0.0001).
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