Gastroparesis Following Nissen Fundoplication and Hiatal Hernia Repair
Nissen fundoplication with hiatal hernia repair is the most reliable and most effective treatment of GERD or acid reflux disease. The procedure is also very safe with less than 1% complication rate. Gastroparesis or delayed gastric emptying is a poorly understood medical disorder. Gastroparesis results from abnormal gastro-duodenal motility resulting in nausea, vomiting, bloating, epigastric pain and early satiety. Gastroparesis can also contribute to acid reflux disease. GERD is a multi-factorial problem and is closely related to gastric motility. Indeed, gastric fundus compliance, relaxation, food accommodation and luminal pressure affects transient lower esophageal sphincter relaxation, TLESR. TLESR is believed to be the main cause of acid reflux. It is not surprising for gastroparesis patients to suffer from heartburn and other GERD related symptoms. In fact, both GERD and gastroparesis may represent different aspects of the same problem related to esophago-gastro-intestinal dysmotility.
Many GERD patients undergoing Nissen fundoplication and hiatal hernia repair surgery may also have undiagnosed gastroparesis. Around 40% of GERD patients suffer from delayed gastric emptying. Nissen fundoplication increases gastric emptying and is sometimes associated with dumping especially in children. Wrapping the fundus around the esophagus decreases gastric compliance possibly leading to increased gastric emptying. The same mechanism of action may also be at play in the case of sleeve gastrectomy. By resecting the gastric fundus, gastric compliance decreases and emptying increases. Consequently, Nissen surgery improves gastric emptying and it contributes to gastroparesis symptom resolution.
In a minority of patients, Nissen surgery is associated with post-operative gastroparesis symptom development. These patients develop nausea, bloating, and pain in the first few days after Nissen surgery. It is unclear whether the surgery itself causes de novo gastroparesis or if it exacerbates an already existing problem with gastric emptying. It has always been assumed that vagal nerve injury results in gastric stasis and failure of the pylorus to relax. Pyloromyotomy has also been advocated in vagotomy cases. Swanstrom et al published a study in 2009 in Archives of Surgery titled “Outcomes of Nissen Fundoplication in Patients with Gastroesophageal Reflux Disease and Delayed Gastric Emptying”. He recommends the addition of pyloroplasty to Nissen fundoplication in cases of delayed gastric emptying. In my experience, pyloromyotomy, like other drainage procedures, has minimal effect on gastric emptying. Gastric emptying is a highly coordinated myo-electrical process. Many feedback signals, in addition to the vagus nerve, modulate this activity. It is unlikely that post-operative gastroparesis is the sole result of vagal nerve injury.
In 2004, a study published by Masclee et al, in the Annals of Surgery showed that laparoscopic fundoplication increases gastric emptying independent of vagal nerve function. The authors nicely showed that 10% of fundoplication patients developed vagal nerve dysfunction post-operatively without affecting gastric emptying or the efficacy of fundoplication in controlling acid reflux. The etiology of gastric stasis is following Nissen surgery remains unclear. There are no established treatment guidelines for gastroparesis. Medications, gastric pacing and drainage procedures are not effective solutions. Subtotal gastrectomy and gastric bypass are associated with poor outcomes. Longitudinal gastrectomy with or without duodeno-jejunostomy seems to be very effective in curing gastroparesis. I have developed this technique several years ago and I have had the chance to apply it on 4 patients so far. Last year, a young man with gastroparesis following fundoplication surgery at an outside institution presented to my office. I performed a longitudinal gastrectomy while preserving the fundoplication and antrum. His symptoms improved immediately. A post-operative UGI study on day one after surgery showed normal gastric emptying. The patient is 8-month post-op now and still doing great.
In summary, gastroparesis and gastric emptying remain poorly understood. However, a tailored longitudinal gastrectomy, even in the presence of a fundoplication, may be an effective and durable solution for gastroparesis. Additional studies are needed to establish this approach as the standard of care treatment for gastroparesis.