Does Nissen Fundoplication Affect the Magenstrasse?
In his seminal paper, “A Stomach Road or Magenstrasse for Gastric Emptying”, James Brasseur concludes that the coordination of contractile waves between gastric fundus and antrum determines the magnitude of the Magenstrasse. Surgical manipulation of gastric fundus in the form of Nissen fundoplication alters antral wall compliance and contractions. As a result, Nissen fundoplication may change the Magenstrasse emptying. Indeed, post-Nissen fundoplication contrast studies demonstrate rapid contrast emptying along the lesser curvature into the duodenum (see above picture). Several studies have demonstrated accelerated gastric emptying following Nissen fundoplication. Some patients, especially children, experience dumping. Post-prandial dumping following Nissen fundoplication in children has been associated with increased levels of GLP-1. GLP-1 secretion is closely associated with food particle emptying along the Magenstrasse.
Reinforcement of the Magenstrasse emptying may be an unintended consequence or wrapping the gastric fundus around the distal esophagus. It may also be one of the anti-reflux mechanism created by Nissen fundoplication. Indeed, abnormal gastric emptying and gastric fundus relaxation result in GERD. In other words, a dysfunctional Magenstrasse may be contributing to GERD. Nissen fundoplication cures GERD, in part, by restoring the Magenstrasse.
Using Brasseur’s computer simulation model of the stomach, one can numerically calculate intra-gastric fluid motions and study the effect of Nissen fundoplication on the Magenstrasse. In cases of severe gastroparesis and GERD, I perform a Nissen fundoplication coupled with a longitudinal gastrectomy to promote gastric emptying. I have done 4 such cases this year with great outcome. Adding a longitudinal along the greater curvature further enhances gastric emptying and probably it reinforces the Magenstrasse. Gastric motility patterns and emptying are complex and poorly understood. Yet, many diseases, like GERD, that have reached epidemic levels in our society, are partly the result of gastro-duodenal motility disorders. Understanding the basic physiology of gastric emptying may help elucidate the etiology of complex problems like GERD and lead to the development of newer less invasive therapies.