Spence from Cypress, Texas sent us this question: “Hello. I’m a 31-year-old male with a hiatal hernia and gastroparesis. I’ve dealt with severe heartburn since my teen years and in the last 7 or 8 years it’s run my life. I have vomiting episodes that last upwards of a day sometimes. I’m on Dexilant and famotidine and even with those, if I don’t sleep perfectly elevated up, I’ll wake up with stomach acid choking me in my lungs and it also in my sinuses behind my eyes. My insurance isn’t the best, so I’ve been going through the motions for years now, months or even up to a year in between tests/visits. My day-to-day life is full of uncomfortable feelings and a ton of fear. Fear that an episode will start and ruin the day of my family. Now I have a final endoscopy scheduled for August and I should hopefully be scheduled for the Nissen procedure shortly after. Now to the issue, my wife fears the procedure and I can see no other alternative because living the way I am now, is not an option for the rest of my life. I can’t even bend over for more than 10 seconds after eating without everything flowing right back up. Anyways, like I said I’m 31 and hopefully should have no problems recovering, but my wife thinks this isn’t an all-out fix and she thinks my gastroparesis won’t get better. I can’t see another way of me having a normal healthy life without it, so my question is, does it seem like this procedure is the best course of action for someone like me? Thanks for your time and I look forward to hearing back. Have a great day”.
Dear Spence,
Severe acid reflux disease is quite debilitating. Concomitant gastroparesis makes day-to-day life unbearable as you explain in your question. Fortunately, we have safe and effective solutions for both GERD and gastroparesis. Concomitant GERD and gastroparesis are rare. It is sometimes hard to differentiate if gastroparesis started first and resulted in GERD and hiatal hernia development, or if gastroparesis developed at a later stage, and GERD was the primary problem. In either case, thorough evaluation, and comprehensive testing by an EXPERT acid reflux specialist is crucial to tailor the best solution for your condition.
Heartburn surgery or anti-reflux surgery restores the anti-reflux barrier in order to stop acid reflux. The most reliable surgery to recreate the anti-reflux barrier and stop heartburn is Nissen fundoplication and hiatal hernia repair. Nissen fundoplication is performed by wrapping the upper part of the stomach around the distal esophagus. The wrap, by itself, enhances gastric emptying and mild gastroparesis tend to resolve after Nissen fundoplication.
For moderate gastroparesis, a pyloroplasty is added to Nissen fundoplication to enhance gastric emptying. An alternative to pyloroplasty is a limited antrum preserving longitudinal gastrectomy that extends up to fundoplication level. I personally prefer partial gastrectomy over pyloroplasty because it makes more physiologic sense. Partial gastrectomy promotes gastric emptying. When added to fundoplication, an antrum preserving partial gastrectomy effectively and safely enhances gastric emptying.
For severe gastroparesis, hiatal hernia repair and an antrum preserving longitudinal gastrectomy including gastric fundus are recommended. In this case, it is felt that acid reflux is a consequence of gastroparesis rather than a co-existing or primary disease. By restoring normal gastric emptying, acid reflux symptoms resolve. Of course, any size hiatal hernia must be corrected at the same time as partial gastrectomy to stop acid reflux. Most severe gastroparesis cases are associated with a dilated stomach. Gastric fundus is usually quite large. Fundoplication is this setting is not likely to promote gastric emptying and less likely to stop acid reflux.