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PERSISTENT POST-FUNDOPLICATION DYSPEPSIA: THE DIAGNOSTIC ROLE OF BODY SURFACE GASTRIC MAPPING
Mohammad Bashashati
*1, Elisa Furay
1, Thomas Neel
1, Lisa Hadorn
1, Deepak Agrawal
1, Christopher N. Andrews
2, F. Paul Buckley
11The University of Texas at Austin Dell Medical School, Austin, TX; 2University of Calgary, Calgary, AB, Canada
Background: Dyspepsia symptoms including nausea and vomiting are temporary complications of foregut surgery which in some cases may be sustained. These patients are usually grouped as post-surgical gastroparesis, blaming this on vagal nerve injury. Body surface gastric mapping (BSGM; Alimetry, New Zealand) is a novel FDA-approved high-resolution electrogastrography that records through 64 electrodes on the abdominal wall and classifies patients with dyspepsia into 8 categories: gastric neuromuscular disorder, myopathy, gastric outlet resistance, impaired pacemaker function, impaired accommodation, disorders of the gut-brain axis, small bowel disorders, and vagal nerve injury. Here, we report 3 post-surgical cases with persistent dyspepsia who underwent BSGM.
Case Presentation: Case 1: A 61-year-old female with fundoplication 15 years before her current visit and robotic redo hiatal hernia repair with revision of fundoplication to posterior 180
o wrap 1 year ago, was referred for chronic nausea and abdominal pain. Her gastric emptying was normal. BSGM revealed normal spectral analysis [principal gastric frequency: 3.1 cycles per minute (CPM), BMI-adjusted amplitude: 39.7?V, and Fed: Fasted Amplitude Ratio: 3.99] suggesting intact vagus nerve, but poor fundic accommodation. She underwent surgery which revealed a twisted fundoplication wrap. The twisted wrap was loosened and post-op follow-up revealed improvement in her gastrointestinal symptoms.
Case 2: 59-year-old male 7 months post laparoscopic redo paraesophageal hernia repair (PEHR) with revisional fundoplication continued to have an inability to belch, bloating, and hiccups. BSGM had a normal principal gastric electrical frequency (3.03 CPM) with normal BMI-adjusted amplitude (30.2 ?V) and Fed: Fasted amplitude ratio (2.9) with no association between symptoms and electrical activity. Findings indicated disorders of gut-brain interaction (DGBI). Therefore, the patient was started on nortriptyline.
Case 3: 48-year-old male post robotic PEHR with Nissen fundoplication with robotic redo PEHR with the conversion of Nissen to Toupet fundoplication 3 years later presented with nausea and vomiting, epigastric pain, and heartburn. Gastric emptying test showed 23% retention at 1 hour consistent with rapid emptying. BSGM showed an overall principal gastric frequency of 3.44 CPM which was elevated. The BMI-adjusted amplitude of 43.5 ?V and Fed: Fasted Amplitude Ratio of 1.8 were all normal. BSGM findings suggested vagal neuropathy. Repeat endoscopy showed a 3 cm hiatal hernia. Neuromodulators did not help. The plan is to undo the fundoplication per the patient’s request.
Conclusions: Patients with sustained post-fundoplication dyspepsia can be categorized based on BSGM into vagal neuropathy, visceral hypersensitivity, and altered accommodation groups. Their management can be customized based on BSGM findings.
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