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

Introduction: 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 following NF. Methods: We analyzed 554 patients who underwent primary NF at our institution and completed postoperative GERD-HRQL questionnaires. GBS was defined as a gas-bloat symptom score ≥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, PPI use, pH normalization, and revisional surgery were compared between patients with and without GBS. Results: At one 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 PPI 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: Gas bloat syndrome is associated with worse postoperative quality of life, higher rates of anatomical failure, and increased revisional surgery after Nissen fundoplication. Routine identification and longitudinal monitoring of GBS may help guide postoperative management and improve long-term outcomes.