Gastric Diverticulum and Heartburn Treatment

53-year-old male presents for evaluation of severe acid reflux related symptoms poorly responsive to medical treatment. His symptoms include heartburn and food regurgitation. Upper endoscopy revealed large hiatal hernia, distal esophagitis, and a posterior gastric fundus diverticulum measuring around 5 by 5 cm. The gastric fundus diverticulum mucosa showed no ulceration or inflammation. Patient denied history of anemia, hematemesis or melena.

After thorough acid reflux evaluation and complete GERD staging decision was made to proceed with laparoscopic hiatal hernia repair and Nissen fundoplication. Laparoscopic hiatal hernia repair and Nissen fundoplication surgery are currently the most reliable treatment for heartburn in Houston. Other procedures like transoral endoscopic fundoplication and LINX surgery are less effective in alleviating heartburn, food regurgitation and other GERD related symptoms. Nissen fundoplication, at Houston Heartburn and Reflux Center, is close to 99.9% effective in stopping acid reflux.

During surgery, the gastric fundus diverticulum was surrounded with dense adhesions that were carefully dissected to completely mobilize the posterior gastric fundus in preparation for a short and floppy Nissen fundoplication. Patient had no contraindications for Nissen fundoplication on esophageal manometry. Esophageal manometry is a test performed prior to anti-reflux surgery to evaluate esophageal contractions and lower esophageal sphincter pressure. Esophageal manometry is an important part of GERD treatment. GERD management depends on accurate testing to confirm and stage acid reflux prior to surgical intervention.

The mobilized gastric fundus was then passed through the retro-esophageal window and rocked back and forth to make sure there is adequate mobilization. The diverticulum was found to be part of the right aspect of the fundoplication and if left unresected it may cause gastric inlet obstruction. Gastric diverticulae are rare and may be associated with bleeding, malignancy, and perforation. Large gastric diverticulae may cause dyspepsia and epigastric pain. A gastric fundus diverticulum is not likely to cause heartburn or contribute to acid reflux. The current patient had an asymptomatic diverticulum discovered incidentally on upper endoscopy while evaluating his acid reflux disease. Since the diverticulum was involving the fundoplication and may cause obstruction decision was made to resect it. Resection was performed with a linear mechanical stapler that was applied at the diverticulum base. A short and floppy Nissen fundoplication was then easily constructed around the distal esophagus.