MJ from Houston sent us this question:” Hi, my daughter had laparoscopic partial Nissen fundoplication for hiatal hernia repair three years ago. She has had constant stomach air and now her gallbladder is not functioning (HIDA Scan 0%). She is 20 and a college runner. Is the gallbladder issue related to her Nissen fundoplication surgery? Thanks”
Dear MJ,
Several small studies in the literature suggest that gallbladder ejection fraction decreases after cutting the hepatic branch of the vagus nerve. The hepatic branch of the vagus nerve is a small nerve that runs along the medial aspect of the upper stomach. It innervates the gallbladder among other structures, and it promotes gallbladder contraction. Hepatic branch of vagus nerve is commonly sacrificed during hiatal hernia repair and Nissen fundoplication, in order to mobilize the upper stomach. Accordingly, gallbladder contractions may decrease, and stone formation may be promoted.
However, gallbladder contractions and overall function are mediated by numerous other factors and signals. Hence, it is not clear to what extent does cutting the hepatic branch of vagus nerve contribute to gallbladder dysfunction.
Indeed, a study published by my colleagues at the university of North Carolina showed improvement in gallbladder ejection fraction after Nissen fundoplication. The study also showed no effect of cutting the hepatic branch of vagus nerve on gallbladder ejection fraction. The authors believe that chronic proton pump inhibitor use like Nexium and Omeprazole contribute to gallbladder stone formation and biliary dyskinesia. Nissen fundoplication stops acid reflux and allow GERD patients to stop PPIs leading to improvement in gallbladder function.
Finally, constant air is not a sign of biliary dyskinesia and is not an indication for gallbladder surgery even in the setting of positive HIDA scan. I caution my patients against unindicated gallbladder surgery in the setting of atypical symptoms like bloating. Unless patient is suffering from right upper quadrant pain, worse with fatty food consumption and associated symptoms like nausea and vomiting, gallbladder resection should be avoided. There are many other causes for gas and bloating. A careful workup prior to any surgical intervention, including the commonly performed laparoscopic cholecystectomy, is always warranted.