Gastrointestinal Complaints After Fundoplication: Rapid Review and Evidence Mapping

Purpose of review: Fundoplication is still the cornerstone of surgical intervention for patients with gastroesophageal reflux disease unresponsive to medical management. While generally successful in resolving typical symptoms and improving patients’ quality of life, post-fundoplication symptoms unrelated to anatomical failure occur in a notable proportion of individuals. These complaints include persistent dysphagia, gas-bloat syndrome, delayed gastric emptying, dumping syndrome, chest pain, and diarrhea. Advances in physiological research has contributed to a more comprehensive understanding of the pathogenesis, prevention, and management of these postoperative symptoms. Findings: This review synthesizes recent literature regarding gastrointestinal functional complaints following fundoplication, with emphasis on pathophysiology, diagnostic approaches, and evidence-based management strategies. Post-fundoplication complaints may be associated with incomplete preoperative work-up, untailored surgical procedure, defective surgical technique, or pre-existing disorders. Persistent dysphagia, gas-bloat syndrome, delayed gastric emptying, diarrhea, chest pain, and dumping syndrome are reported in up to 50%, 50%, 40%, 20%, 20%, and < 1% of patients, respectively. Various contributing factors have been identified, including defective esophageal motility and functional reserve, decrease of the fundic accommodation reflex, technical aspects of fundoplication and cruroplasty, iatrogenic injury to the vagus nerve, and exacerbation of pre-existing irritable bowel symptoms. Complete preoperative workup, patient’s education, and intraoperative EndoFLIP impedance planimetry have the potential to mitigate the incidence of persistent symptoms. The integration of artificial intelligence and machine learning algorithms offers promise for risk stratification and may enhance the prediction of postoperative functional outcomes. Summary: Functional gastrointestinal complaints are commonly encountered following fundoplication and can influence surgical outcomes, potentially impacting patients quality of life and overall satisfaction. A comprehensive knowledge of the underlying pathophysiological mechanisms is essential for optimizing patient selection, refining surgical approaches, planning targeted management strategies, and enhancing long-term functional results.