Bowel dysfunction after laparoscopic antireflux surgery: incidence, severity, and clinical course
Article Outline
Abstract
Purpose
To evaluate the incidence, severity, and clinical course of postoperative bowel dysfunction, primarily diarrhea, after laparoscopic antireflux surgery.
Methods
Patients who underwent laparoscopic antireflux surgery during January to December 1998 responded to a questionnaire about pre-existing and postoperative bowel symptoms, which included questions about the type of bowel dysfunction (diarrhea, abdominal pain, bloating, constipation), onset in relation to surgery, frequency, severity, duration, use of medical resources or diagnostic evaluations, and treatment outcome.
Results
Of the 109 patients who underwent laparoscopic antireflux surgery at our center during the study, 84 (77%) completed the survey. Thirty-six (43%) had no bowel dysfunction before or after surgery, whereas 29 (35%) had pre-existing bowel dysfunction. New bowel symptoms developed postoperatively in 30 patients (36%), including bloating in 16 (19%) and diarrhea in 15 (18%). Two thirds of the patients with new diarrhea developed it within 6 weeks after surgery. The severity of the diarrhea ranged from mild to debilitating; 4 had fecal incontinence. Most patients (13/15) with diarrhea had symptoms for ≥2 years following surgery. No patient was hospitalized, and only 2 patients reported temporary work loss.
Conclusion
Postoperative bowel dysfunction, namely diarrhea, is an important adverse effect of antireflux surgery. Awareness of this complication should lead to prompt recognition, effective management, and reduction in anxiety.
Since its description in 1991 by Dallemagne et al. (1), laparoscopic antireflux surgery has become an accepted treatment for severe uncontrolled gastroesophageal reflux disease. Ten years of experience indicate that laparoscopic antireflux surgery provides good short- and long-term results 2, 3, 4, 5, 6, 7, 8. Surgeons and gastroenterologists are aware of perioperative and postoperative problems such as transient dysphagia, gas bloat, and early satiety. However, postoperative bowel dysfunction after laparoscopic antireflux surgery, particularly diarrhea, has not received wide recognition. In the past few years, we have observed that some patients have experienced unexpected bowel dysfunction (mainly diarrhea) following laparoscopic antireflux surgery. The aims of this study were to evaluate the incidence, frequency, severity, and clinical course of postoperative bowel dysfunction, primarily diarrhea, in a consecutive series of patients who underwent laparoscopic fundoplication.
Methods
Study sample
All consecutive patients who underwent laparoscopic antireflux surgery from January to December 1998 at the Mayo Clinic, Jacksonville, Florida, were included. Their medical records were reviewed for demographic characteristics, type of surgery, clinical course, and outcome. A comprehensive gastrointestinal history is obtained preoperatively in all patients considered for laparoscopic antireflux surgery at our center. In addition, the patients were asked to complete a questionnaire to evaluate bowel symptoms predating and following their surgery. To be included, patients had to have either a laparoscopic 360-degree Nissen fundoplication or laparoscopic 270-degree Toupet fundoplication. Preoperative testing included esophageal manometry, esophagogastroduodenoscopy, or 24-hour pH testing to evaluate gastroesophageal reflux disease.
Surgical procedure
The choice of the laparoscopic antireflux procedure was based on the results of esophageal manometry. Patients with poor esophageal body motility underwent a partial Toupet fundoplication, whereas patients with normal esophageal body motility underwent a 360-degree Nissen fundoplication (9). Our surgical technique has been described elsewhere (10).
Questionnaire
All patients were contacted by telephone after their surgery. Questions included the type of bowel dysfunction before and after surgery (diarrhea, abdominal pain, bloating, constipation), onset in relation to surgery, frequency, severity, duration, use of medical resources or diagnostic evaluations, and treatment outcome. Severity of bowel symptoms was rated on a scale of 1 (minimal symptoms) to 10 (severe symptoms). The patients were kept unaware of the study’s purpose or hypothesis. Data provided by the patients were corroborated by chart review when possible. The Mayo Clinic Institutional Review Board approved the study protocol.
Results
Of the 109 patients who underwent laparoscopic antireflux surgery at our center from January to December 1998, 84 (77%) completed the survey (Table) and answered the questionnaire (21 were lost to follow-up, 3 live outside the United States, and 1 died of an unrelated cause). The mean (± SD) follow-up was 28 ± 3.4 months (range, 23 to 34 months). Overall, 36 patients (43%) did not have any bowel problems before or after surgery. Bowel dysfunction before surgery (one or more symptoms) was reported by 29 patients (35%) (Figure 1), including constipation (n = 15), diarrhea (n = 14), bloating (n = 3), and abdominal pain (n = 2). Eleven (38%) of these patients developed new symptoms (Figure 1). After surgery, 48 patients (57%) reported some form of bowel dysfunction; in 30 (36%), this was a new symptom since surgery. Of the 55 patients without any preoperative bowel dysfunction, 19 (35%) reported one or more completely new symptoms (Figure 1). The most common symptoms were diarrhea (18%) and bloating (19%), both of which were more common after surgery (Figure 2). New-onset bloating was reported by 16 patients, with a mean severity of 6.2 ± 2.5 (range, 2 to 10). Bloating improved in 3 patients during a 2-year period, but at the time of the survey, all of these patients complained of persistent bloating.
Table. Characteristics of the 84 Patients Who Underwent Laparoscopic Antireflux Surgery
| Characteristic | Number (%) or Mean ± SD |
|---|---|
| Female sex | 54 (50) |
| Age (years) | 59 ± 15 |
| Laparoscopic Nissen fundoplication | 73 (87) |
| Laparoscopic Toupet fundoplication | 11 (13) |
| Duration of preoperative reflux symptoms (months) | 131 ± 100 |
| Hospital stay (days) | 1.5 ± 1.4 |
Figure 1.
Number and percentage of 84 patients with preoperative and postoperative bowel symptoms. Note that the sum of the numbers of patients expressed in the two boxes on the extreme right do not add up, because several of the patients reported more than one symptom.
Figure 2.
Number and percentage of 84 patients with specific symptoms.
New-onset diarrhea developed in 15 patients, 10 (67%) of whom experienced this symptom within the first 6 weeks after surgery. Twelve of the patients had undergone a Nissen fundoplication; 3 had undergone a Toupet procedure. The mean number of days with diarrhea per week was 2.7 ± 0.7 days (range, 2 to 10 days), and the mean frequency of bowel movements per day was 2.7 ± 0.6 (range, 2 to 4). The mean severity score for diarrhea was 6.5 ± 2.9 (range, 2 to 10). Diarrhea led to fecal incontinence in 4 patients. A mean of 7.7 ± 2.2 kg in weight lost was reported by 4 patients, presumably attributable to diarrhea. Diarrhea led to temporary work loss in 2 patients (2 days each). In 7 patients with diarrhea, diagnostic tests such as stool sample collections or endoscopy were required for further evaluation, although no specific etiology for the symptom was identified. None of these patients was hospitalized. The mean duration of diarrhea was 24 ± 11.3 months (range, 3 to 28 months). After a 2-year period, 13 of the 15 patients are still experiencing diarrhea, although 7 reported partial spontaneous improvement and did not require medication for bowel control. The remaining 6 patients require medication to control their diarrhea (antimotility agents were prescribed in 5 and cholestyramine in 1).
Discussion
Laparoscopic antireflux surgery is an effective procedure with fewer major perioperative complications than those described in series utilizing the open approach 11, 12, 13, 14. Intraoperative complications such as esophageal perforation, bleeding, or the development of a pneumothorax occur in 1% to 2% of patients (5). With experience, a conversion rate to an open approach of 0.1% has been reported, and the failure rate of the procedure is as low as 3.4%, emphasizing excellent control of gastroesophageal reflux (5). After a follow-up of 5 to 8 years after surgery, 96% of patients reported being satisfied with the procedure (6).
Several series have addressed side effects or postoperative complications of antireflux surgery. The most common postoperative symptoms are bloating and transient dysphagia 7, 8, 15. We were particularly interested in learning whether postoperative bowel dysfunction was due to unrecognized pre-existing bowel dysfunction. Indeed, we found that 35% of our patients had bowel symptoms before surgery. A previous report noted that as many as 66% of patients who underwent antireflux surgery had pre-existing irritable bowel syndrome (15). These observations underscore the ubiquitous nature of bowel dysfunction in this sample and stress the value of obtaining a comprehensive preoperative gastrointestinal history in patients undergoing laparoscopic antireflux surgery. Had we not considered pre-existing symptoms, we would have overestimated postoperative bowel dysfunction. Of interest, 43% of patients undergoing laparoscopic antireflux surgery did not experience any bowel problems before or after surgery; in 21%, the same symptom was experienced before and after surgery. However, new-onset bowel dysfunction occurred in 36% of the patients.
Diarrhea was the second most frequent postoperative symptom (after bloating) in our sample; it was reported by 18% of patients. Few previous reports have addressed this complication, and even fewer have examined whether this symptom was present before surgery. In the available series, postoperative diarrhea has been reported in 25% to 33% of patients after laparoscopic antireflux surgery 15, 16, 17. The higher percentages in these reports may be due to pre-existing bowel symptoms. In addition, in one study postoperative diarrhea was noted in half of the patients who had undergone simultaneous cholecystectomy (15). Only 1 of our patients with diarrhea had also undergone a cholecystectomy.
We found that 10 of the 15 patients with new diarrhea had an onset of symptoms within 6 weeks of surgery. Four patients also reported fecal incontinence, and diarrhea was often persistent. However, severe or uncontrollable diarrhea occurred in the minority of our patients, none required hospitalization, and all of those with persistent diarrhea responded favorably to symptomatic medical treatment (mostly antimotility agents or empirical therapy with cholestyramine). Unfortunately, only 7 of these patients underwent diagnostic tests, and the cause of diarrhea in these patients remains to be determined.
Following laparoscopic antireflux surgery, gastric emptying is increased and postprandial gastric relaxation is reduced (18). It is possible that enhanced gastric emptying contributes to a more rapid gut transit time and leads to diarrhea. Transit time scintigraphy may help elucidate this possibility. Diarrhea may also be related to an inadvertent vagotomy. However, in our series the posterior vagal nerve was always visualized during the procedure to avoid damage. In patients with a 360-degree Nissen fundoplication, it is unlikely that the anterior vagal nerve is damaged, because the sutures for the wrap are placed far from the expected position of the vagus. From the surgical point of view, the 270-degree Toupet fundoplication would be more likely to cause anterior vagal nerve damage, because the sutures are placed closer to the tenth cranial nerve in the esophagus. The number of patients with diarrhea was too small to determine whether it was more common following Toupet fundoplication. Other studies have also failed to demonstrate that vagotomy is a common occurrence after laparoscopic antireflux surgery (18). Diarrhea may be due to other mechanisms. For instance, patients tend to modify their dietary intake following surgery. Liquid and bland diets are commonly favored by patients, sometimes because of postoperative dysphagia.
The retrospective nature of our study could have contributed to recall bias. We attempted to reduce this problem by asking about a range of symptoms (abdominal pain, bloating, constipation) and not only about diarrhea. Furthermore, a chart review was done to complement the patient’s recall. It would be interesting to know if there is any relation between diarrhea postoperatively and control of acid reflux. However, postoperative esophageal testing (including endoscopy) was not done routinely in these patients. Thus, we cannot answer this question.
In conclusion, diarrhea and abdominal bloating are the most common bowel symptoms after laparoscopic antireflux surgery. New-onset postoperative diarrhea arises mostly within 6 weeks after surgery. Although postoperative bowel dysfunction may not require aggressive therapy, it can create concern in both the uninformed patient and their attendant physicians. Awareness of the clinical course and development of this symptom in the postoperative period may decrease anxiety and concern in patients and physicians. Future studies are needed to identify the mechanisms responsible for these symptoms.
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PII: S0002-9343(02)01301-3
doi:10.1016/S0002-9343(02)01301-3
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