Gas Bloat Syndrome after Nissen Fundoplication: Association with Anatomical Failure and Revisional Operation

BACKGROUND: Gas bloat syndrome (GBS) is a recognized complication of Nissen fundoplication (NF), characterized by impaired gastric venting and progressive distention. Although its negative impact on quality of life is well established, the relationship between GBS, anatomical failure, and revisional surgery remains unclear. This study evaluated the association between GBS, clinical outcomes, anatomical integrity, and reoperation after NF. STUDY DESIGN: We analyzed 554 patients who underwent primary NF at our institution and completed postoperative GERD-Health-Related Quality of Life (GERD-HRQL) questionnaires. GBS was defined as a gas bloat symptom score greater than or equal to 4 at 1 year. Anatomical failure was defined by endoscopic evidence of recurrent hiatal hernia or fundoplication disruption. GBS was classified as new-onset or persistent based on preoperative symptoms. Clinical outcomes, including GERD-HRQL, patient satisfaction, proton pump inhibitor use, pH normalization, and revisional surgery, were compared between patients with and without GBS. RESULTS: At 1 year, 24.7% of patients met criteria for GBS. Compared with patients without GBS, those with GBS had higher GERD-HRQL scores, lower satisfaction, and greater proton pump inhibitor use (all p < 0.01). By postoperative year 5, anatomical failure occurred more frequently in patients with GBS (46.7% vs 15.3%, p < 0.0001) and occurred earlier (median 22 vs 32 months, p = 0.0012). Revisional surgery was more common in the GBS group (28.5% vs 8.5%, p < 0.001). Outcomes were similarly poor in patients with new-onset and persistent GBS. Delayed gastric emptying did not predict symptom severity or clinical outcomes. CONCLUSIONS: GBS is associated with worse postoperative quality of life, higher rates of anatomical failure, and increased revisional surgery after NF. Routine identification and longitudinal monitoring of GBS may help guide postoperative management and improve long-term outcomes.