Pregnancy and delivery after antireflux surgery

Unusual case of hyperemesis in a pregnant patient with prior antireflux surgery

A 33-year-old, 8 weeks pregnant, presented with severe upper abdominal pain with vomiting on a background of a previous laparoscopic Nissen fundoplication for reflux disease. An urgent MRI had shown herniation of the fundoplication wrap through the diaphragmatic hiatus. The cause of her symptoms was attributed to hyperemesis gravidarum. The plan was to manage this patient conservatively until the conclusion of her pregnancy. This plan was revised when she presented for the second time and developed worsening pain and haematemesis. An emergency gastroscopy showed ischaemic changes in most of the stomach requiring the patient to undergo an emergency laparotomy. In pregnant patients, presenting with abdominal pain, vomiting as well as haematemesis, having had previous antireflux surgery, incarceration of the stomach must be considered as a differential. Prompt assessment and early senior decision-making is extremely important in avoiding a potentially catastrophic outcome for such patients.

Acute gastric incarceration from thoracic herniation in pregnancy following laparoscopic antireflux surgery

Diaphragmatic hernia is a rare complication in pregnancy which due to misdiagnosis or management delays may be life-threatening. We report a case of a woman in the third trimester of pregnancy who presented with sudden onset of severe epigastric and thoracic pain radiating to the back. Earlier in the index pregnancy, she had undergone laparoscopic antireflux surgery (ARS) for a hiatus hernia because of severe gastro-oesophageal reflux. Owing to increasing epigastric pain a CT scan was carried out which diagnosed wrap disruption with gastric herniation into the thoracic cavity and threatened incarceration. This is, to our knowledge, the first report of severe adverse outcome after ARS during pregnancy, with acute intrathoracic gastric herniation. We recommend the avoidance of ARS in pregnancy, and the need to advise women undergoing ARS of the postoperative risks if pregnancy occurs within a few years of ARS.

Effect of pregnancy on effectiveness of laparoscopic Nissen fundoplication

BACKGROUND

Symptoms of gastroesophageal reflux disease (GERD) are experienced by up to 85% of pregnant women. Some young women on maintenance proton pump inhibitor (PPI) treatment are choosing surgery to stop their medical treatment and avoid severe symptoms during pregnancy. There are no reports describing the effect of pregnancy on the long-term efficacy of laparoscopic Nissen fundoplication. The aim of this study was to evaluate the effect of pregnancy on the efficacy of laparoscopic Nissen fundoplication.

METHODS

This study surveyed 146 women of childbearing age with proven GERD who had undergone laparoscopic Nissen fundoplication from 1992 through 2002. The patients who became pregnant (group 1) were compared with those who did not (group 2).

RESULTS

The study focused on 25 patients who became pregnant after surgery. Of these patients, 40% (n = 10) had chosen surgery as a way to discontinue PPI treatment before pregnancy. The mean time from laparoscopic Nissen fundoplication to pregnancy was 25.9 +/- 4.6 months. A total of 19 patients (76%) had no reflux symptoms, whereas 5 (20%) required antacids during pregnancy. One patient (4%) experienced an acute intrathoracic stomach migration during her pregnancy and required emergency open surgery, which resulted in the loss of her fetus. After pregnancy, six patients (24%) had recurrence of GERD symptoms, and three (12%) required a redo fundoplication. The higher rate of GERD recurrence (24% vs 16.7%) and redo surgery (12% vs 4%) in group 1 did not reach statistical significance, but showed a definite trend.

CONCLUSION

For most patients, laparoscopic Nissen fundoplication is effective in controlling GERD symptoms during and after pregnancy.