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DOR FUNDOPLICATION EFFECTIVELY TREATS GASTROESOPHAGEAL REFLUX DISEASE IN PATIENTS WITH CONCOMITANT GASTROPARESIS
Danny J. Avalos*, Evan Liggett, Vladimir Paez, Richard W. McCallum, Brian R. Davis
Texas Tech Health Sciences Center E, El Paso, TX
Background:
Refractory gastroesophageal reflux disease (GERD) in patients with concomitant gastroparesis (GP) particularly uncontrolled nocturnal regurgitation results in an overall poor quality of life with limited therapeutic options. Nissen fundoplication is associated with gas-bloat syndrome due to an impaired belching reflex. In GP patients, where intermittent vomiting may still occur, instead of a standard Nissen fundoplication, a partial 270 degree wrap (Dor fundoplication), provides relief of refractory reflux while at the same time minimizing post-surgical dyspepsia symptoms and permits belching and vomiting to occur.
Methods:
Four patients with refractory GERD and GP seen at the Texas Tech University motility center and surgical outpatient clinics were referred for Dor fundoplication between 2015-2016. In addition to collecting demographic and social history data, patients were interviewed after surgery using the Gastroparesis Cardinal Symptom Index Questionnaire (GCSI). Patients were also asked for pre and post anti-reflux medication doses, a self-reported assessment for overall symptomatic improvement particularly focusing on nocturnal regurgitation, gas-bloat syndrome, and belching in addition to any new post-operative symptoms. Institutional Review Board approval was obtained for data collection.
Results:
Four patients underwent Dor fundoplication with an average age of 50.3 years old (range 39-68). Three patients had idiopathic gastroparesis (IG), and one had hypomotility from scleroderma. Two out of 4 patients required placement of gastric electrical stimulators. Pre-surgical treatment, in addition to maximizing life-style aspects, included 30-60mg dexlansoprazole with BID dosing and pantoprazole 40mg BID. Average follow-up at time of questionnaire was 13.5 months (range 2-18).
The mean post-surgical GCSI score was 17.8 (range 7-25) similar to pre-surgical scores. Based on their overall assessment, nocturnal regurgitation was at least 80% reduced and no longer interfered with sleep. As far as post-operative anti-reflux medications, one patient has been able to stop all anti-reflux medications, one was able to reduce PPI dose to once per day, while the other 2 patients remain on their pre-surgical dosage regimens based on continuing presence of day-time reflux symptoms. There was no occurrence of post-operative dysphagia and all patients reported that their belch reflex was intact, although one patient required a carbonated drink to activate the reflex.
Conclusion: A Dor fundoplication in GP patients with refractory GERD effectively addressed their major indication for the surgery, uncontrolled nocturnal regurgitation, while not inducing post-operative dyspepsia and gas-bloat syndrome or negatively affecting GP symptoms.
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