Does Anxiety Affect Nissen Fundoplication Outcome?

The relationship between acid reflux and anxiety is circular. Acid reflux exacerbates anxiety and anxiety exacerbates acid reflux related symptoms. Acid reflux or GERD is a chronic disease with debilitating symptoms that significantly decrease quality of life. Daily heartburn, bloating, and pain as well as constant burping and coughing worsen in intensity and severity as GERD progresses over time. These symptoms can take a toll on a patient’s mental health. They may lead to or, most commonly, worsen pre-existing anxiety and depression. One study did indeed show increased incidence of anxiety and depression in GERD patients. By the same token, psychiatric disorders alter pain perception. Stress and anxiety heighten the perception of acid reflux symptoms like heartburn and chest pain without necessarily increasing the frequency and severity of acid reflux events. Furthermore, some studies show that stress and anxiety decrease lower esophagus sphincter, LES, pressure. A drop in LES pressure may favor acid reflux.

A properly performed hiatal hernia repair and Nissen fundoplication reliably stops acid reflux. It is fair to assume that eliminating acid reflux improves anxiety and depression symptoms. However, we have noticed at Houston Heartburn and Reflux Center, a category of anxious patients with acid reflux who do not seem to improve after anti-reflux surgery. Typically, this group of patients present to our center with severe GERD related symptoms and poorly controlled anxiety symptoms. In addition to classic acid reflux symptoms like heartburn and food regurgitation, patients report nonspecific chest and abdominal pain. Following successful hiatal hernia repair and Nissen fundoplication, patients with severe anxiety continue to report a plethora of acid reflux related and unrelated symptoms. Consequently, they start to lose faith in the Nissen fundoplication as a reliable solution for their acid reflux. In most cases, I end up repeating upper endoscopy and pH Bravo study after surgery to demonstrate the absence of acid reflux and to prove GERD resolution.

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It seems that laparoscopic Nissen fundoplication in patients with anxiety “improves GERD symptom burden but satisfaction is rarely achieved in long-tern follow up” according to a study published in Surgical Endoscopy in 2020 by K Perry et al. The authors retrospectively analyzed 271 Nissen fundoplication patients. 103 patients had depression and 44 had anxiety. They found out that patients with anxiety have higher subjective reporting of GERD related symptoms compared to control, before and after Nissen fundoplication. Both anxiety and GERD are common disorders affecting 25 % of the Houston population. Therefore, it is not uncommon for a patient with acid reflux disease to suffer from co-existing anxiety and/or depression.

At Houston Heartburn and Reflux Center, we recommend anxiety control prior to anti-reflux surgery. We often refer GERD patients with severe anxiety for a psychiatric evaluation and management prior to Nissen fundoplication. We do not proceed with surgery until patient anxiety and depression are well controlled. We also educate our patients to help them differentiate and separate acid reflux from anxiety related symptoms. For instance, we explain to our patients that irritable bowel syndrome, if present, is not related to GERD and it is not likely to resolve after Nissen fundoplication. These pre-operative measures help anxious patients manage their expectations and improve their satisfaction level after Nissen fundoplication.

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