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Updated: Dec 21, 2025
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Published on: August 11, 2023
Postfundoplication retching: Strategies for management
1Department of Paediatric Surgery, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK.
Insights
Postoperative retching in children, especially those with neurodisability, can cause surgical wrap breakdown. Management should focus on the emetic reflex, not gastroesophageal reflux, and avoid fundoplication in at-risk children.
Area of Science:
- Pediatric Surgery
- Gastroenterology
- Neurodisability Research
Background:
- Retching is a frequent complication after antireflux surgery in children, particularly those with neurodevelopmental disorders.
- Retching is a component of the emetic reflex, not a symptom of gastroesophageal reflux disease (GERD), and can lead to surgical wrap disruption.
- The presence of retching indicates nausea and is a distressing symptom that requires dedicated treatment.
Purpose of the Study:
- To develop a management framework for postoperative retching targeting the emetic reflex.
- To evaluate the influence of different antireflux procedures on the occurrence of retching.
- To identify children at risk for postoperative retching prior to surgery.
Main Methods:
- A structured approach was created to manage postoperative retching by addressing various elements of the emetic reflex.
- Consideration was given to how different antireflux surgical techniques affect the incidence of retching.
- Strategies included dietary modifications, antiemetic medications, and pro-motility agents.
Main Results:
- The study framework provides strategies for managing postoperative retching, including dietary adjustments and pharmacological interventions.
- Fundoplication is identified as an inappropriate procedure for children at risk of retching, as it does not address the underlying emetic reflex and may worsen symptoms or cause wrap disruption.
- Alternative management strategies are recommended for symptom control in these patients.
Conclusions:
- Children at risk for postoperative retching can be identified preoperatively.
- Fundoplication should be avoided in children prone to retching due to its ineffectiveness for their symptoms and risk of complications.
- Management should focus on the emetic reflex, utilizing antiemetics, motility agents, and potentially neuromodulation, rather than solely on GERD.
Background:
Retching is a common symptom in children following antireflux surgery, particularly in those with neurodisability. There is now a strong body of evidence that implicates retching as a major cause of wrap breakdown. Retching is not a symptom of gastroesophageal reflux disease; it is a component of the emetic reflex. In addition to causing wrap breakdown, it is indicative of the presence of nausea. It is a highly aversive experience and warrants treatment in its own right.
Methods:
A framework was constructed for the management of postoperative retching, with strategies targeting different components of the emetic reflex. The impact of differing antireflux procedures upon retching was also considered.
Conclusions:
Once treatable underlying causes have been excluded, the approach includes modifications to feeds and feeding regimens, antiemetics and motility agents. Neuromodulation and other, novel, therapies may prove beneficial in future. Children at risk of postoperative retching may be identified before any antireflux surgery is performed. Fundoplication is inappropriate in these children because it does not treat their symptoms, which are not because of gastroesophageal reflux, and may make them worse. They are also at risk of wrap disruption. Alternative strategies for symptom management should be employed, and fundoplication should be avoided.
Level Of Evidence:
II-V.
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