Early Postoperative Symptoms

The management of patients with new or recurrent GERD symptoms after surgery is dependent on the time of presentation. Early postoperatively (<3 months) the presence of several symptoms is extremely common and no treatment or evaluation is necessary.

The most common of these early postoperative symptoms after anti-reflux surgery is dys-phagia. Dysphagia to solids after anti-reflux

MANAGING FAILED ANTI-REFLUX THERAPY

surgery is nearly universal, and the sensation of liquids "hanging up" is not unusual either. The cause of these symptoms postoperatively is likely multifactorial. Distal esophageal edema is seen universally postoperatively, transient esophageal dysmotility has been demonstrated after anti-reflux surgery, and recently performed fundoplication-related hematomas can also cause temporary outflow obstruction from this section of the esophagus. For all these reasons, we recommend that the patients stay on a full liquid diet for the first 5-7 days after surgery, and then follow a special soft diet for the next 3 weeks. This special diet restricts the intake of large bolus foods such as meats, raw vegetables, and high-gluten-containing items such as cakes and breads. This protocol dramatically reduced the incidence of postoperative symptomatic dysphagia, food impaction, and retching that occur when a regular diet has begun too soon after surgery and the associate phone calls expressing alarm over these symptoms that will be the norm if they occur.

Despite these instructions aimed at minimizing postoperative dysphagia, when patients do complain of early postoperative dysphagia, we then instruct them to return to a liquid diet until swallowing again becomes easy and then they can be readvanced to a soft diet. If a patient has difficulty tolerating a full liquid diet, early intervention may now be necessary. These interventions include esophageal dilatation, and/or placement of a nasoenteric feeding tube. In patients who will not tolerate a nasal tube, we have used percutaneous endoscopic gastros-tomy when early postoperative dysphagia became so severe as to cause weight loss or dehydration (Figure 7.1).

Another early postoperative symptom of no great consequence is the development of chest pain or recurrent reflux symptoms. The mecha-nism(s) related to these symptoms remains unclear. However, during the first 3 months after surgery, the patient should be reassured that it is extremely unlikely that the symptoms reflect recurring gastroesophageal reflux, especially if no postoperative events such as retching have occurred. A simple screening study such as a barium swallow may provide the opportunity to provide a worried patient great reassurance that their fundoplication has not come undone. A trial of proton pump inhibitors (PPIs) is often initiated if the patient returns to their primary care provider, but these PPIs are rarely effective for early postoperative difficulties. The best management of most early postoperative complaints is patience and reassurance, not reoperation or other reflux therapy.

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