Kelley from Houston sent us this question: “What if you have gastroparesis? Is a Nissen fundoplication contraindicated? Thank you.”
In theory, Nissen fundoplication is contraindicated in the setting of gastroparesis. Nissen fundoplication re-establishes the anti-reflux barrier. Nissen fundoplication stops any gastric content reflux into esophagus. Gastroparesis patients depends on upward decompression of gastric content into esophagus for stomach propulsive contractions are weak. Consequently, Nissen fundoplication in the setting of gastroparesis may result in worsening bloating, pain, nausea, and dry heaving.
Nissen fundoplication, however, promotes gastric emptying. In a case of mild gastroparesis, Nissen fundoplication may cure both GERD and delayed gastric emptying. Traditionally a pyloroplasty has been added to Nissen fundoplication if gastroparesis is present. The pylorus muscle or gastric outlet valve is cut to facilitate gastric drainage. Such an approach, however, has limited success rate especially in a case of severe gastroparesis.
A more effective solution to promote gastric emptying is an antrum preserving longitudinal gastrectomy. I developed this procedure several years ago and I have had great success with at least 50 gastroparesis patients. After repairing the hiatal hernia and completing the fundoplication, gastric body is longitudinally resected along the Magenstrasse line. Resection stops just below the fundoplication level. The combination of fundoplication and gastric resection addresses both acid reflux and delayed gastric emptying. Promoting gastric emptying increases the durability and efficacy of Nissen fundoplication.
Please note that gastroparesis can result in heartburn and acid reflux. Indeed, most gastroparesis patients have heartburn. Care must be taken to differentiate GERD from gastroparesis as the primary problem. If gastroparesis is the primary problem, treatment consists of antrum preserving longitudinal gastrectomy without fundoplication. The dilated gastric fundus, often associated with gastroparesis, is included in the longitudinal resection to promote gastric emptying. If a hiatal hernia is present a concomitant hiatal hernia repair is performed to prevent acid reflux after surgery.