Gastroparesis, Hiatal Hernia, Heartburn and Gastric Pacemaker

Fundoplication Surgery for Heartburn treatment

Gastroparesis, Hiatal Hernia, Heartburn and Gastric Pacemaker

Mary from Houston sent us this question: “I have severe acid reflux. I take Nexium and another PPI twice a day. I wake up in middle of the night burning like crazy and choking from the acid coming up. I sleep with my bed elevated. I will burn for a couple of hours. I’m have constant postnasal and cough drip which is from the reflux. I have Gastroparesis and have a stimulator. I also have a hiatal hernia that has gotten bigger. My doctors will not do anything with the hiatal hernia or reflux because of the gastroparesis. I need help. I do watch what I eat but it doesn’t matter. Thank You”.

Dear Mary,

Hiatal hernia repair is particularly indicated in the setting of gastroparesis. Delayed gastric emptying promotes stomach content backflow into the esophagus leading to longer and more severe reflux episode. Consequently, you are more likely to have cough and chocking especially at night, when you go to sleep and lay flat on your back.

Hiatal hernia repair by itself, however, is not enough to re-create the anti-reflux barrier. A Nissen fundoplication must be added to hiatal hernia repair to stop acid reflux. Doctors are reluctant, however, to add a Nissen fundoplication in the setting of gastroparesis because you cannot vomit after Nissen fundoplication. Therefore, your gastroparesis symptoms like nausea, vomiting, bloating and abdominal pain may get worse after Nissen fundoplication in the setting of gastroparesis.

To circumvent the problem, a pyloromyotomy has traditionally been performed in conjunction with hiatal hernia repair and Nissen fundoplication to decompress the stomach in case of gastroparesis. Pyloromyotomy may help especially that fundoplication promotes gastric emptying. However, at Houston Heartburn and Reflux Center, we have developed an effective procedure for gastroparesis than entails resecting the lateral side of the stomach while preserving the gastric antrum. We call the procedure and antrum preserving longitudinal gastrectomy. We have had great success in approximately 100 gastroparesis patients so far. In case of concomitant Nissen fundoplication, the stomach is resected from just above the antrum level to just below the wrap.

We believe that this approach is superior to pyloromyotomy in terms of promoting gastric emptying as opposed to simply cutting open the stomach outlet. By the same token, antrum preserving longitudinal gastrectomy avoids bile reflux from duodenum into stomach. Bile gastritis is a commonly encountered with gastroparesis and following pyloromyotomy.

Gastric pacemaker, or stimulator as you call it, does not improve gastric emptying. A gastric pacemaker may, theoretically, worsen acid reflux. This may be your case. I recommend thorough evaluation of your condition prior to any surgical intervention. The co-existence of GERD and gastroparesis complicates management. At Houston Heartburn and Reflux Center, we specialize in both conditions and we make sure we offer our patients the best possible solutions to alleviate these debilitating symptoms and improve quality of life.