Approach and management of patients with recurrent gastroesophageal reflux disease

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.

Nonsurgical factors affecting symptomatic outcomes of antireflux surgery

A small number of patients will have persistent or new symptoms after antireflux surgery for gastroesophageal reflux disease (GERD). Most of these symptoms are due to recurrent reflux or some complication or side-effect of the operation. However, a few of these patients will be symptomatic without objective findings to explain these symptoms. The purpose of this review is to highlight potential non-surgical factors that may proceed to a poor symptomatic outcome after antireflux surgery. These factors include underlying esophageal pathophysiology, issues related to chronic pain and pain perception, personality and psychoemotional disorders, functional esophageal and/or bowel disorders, and the nocebo phenomenon. Awareness of these other causes can lead to more appropriate treatments.

Pregnancy and delivery after antireflux surgery

BACKGROUND

Concerns have been raised that subsequent pregnancy after antireflux surgery (ARS) may predispose to wrap disruption or herniation and adversely affect outcomes. Some surgeons withhold ARS in women of childbearing age for fear of this, but outcomes in this population have not been reported.

METHODS

All childbearing-age women who underwent ARS for gastroesophageal reflux disease (GERD) between January 1991 and July 2000 were asked to complete a detailed questionnaire. Patients with subsequent pregnancies (SP) after ARS were compared with patients without subsequent pregnancies (NP).

RESULTS

Ninety-five of the 118 patients (81%) completed the questionnaire at a mean follow-up of 4.9 years. Fifteen patients had 19 subsequent pregnancies after undergoing ARS, and retching and/or vomiting were reported during 13 of the pregnancies (69%). Preoperative incidence of complicated-GERD including strictures (11% vs. 20%), Barrett's esophagus (19% vs. 13%), esophagitis (36% vs. 33%), and ulceration (4% vs. 0%)-were similar between the nonpregnant and pregnant groups. Incidence of postoperative moderate to severe esophageal (7% vs. 8%) and extraesophageal symptoms (0% vs. 6%) were similar between the SP and NP groups. Postoperative prevalence of antisecretory medications was similar in SP and NP groups (13% and 23%, respectively). The incidence of fundoplications redone did not reach statistical difference between the NP (11%) and SP (0%) groups. Long-term outcomes and failure rates were similar in both groups, except the SP group reported greater overall satisfaction with ARS.

CONCLUSIONS

Women of childbearing age have a high incidence of complicated GERD, which may contribute to higher-than-expected rates of symptomatic and anatomic fundoplication failures than first-time ARS. Subsequent pregnancies do not adversely affect outcomes after ARS.