28 year old female presenting with 6 month history of worsening reflux symptoms. She has had only partial relief with proton pump inhibtors. Promotility agents gave her headaches. EGD showed no esophagitis. 24 hour pH study was boderline abnormal. She had a total of 126 episodes of reflux which all lasted less than 5 minutes in duration. The patient did not feel that the study was an accurate reflection of her pathology because she did not work during the study and most of her symptoms usually occured at work when she is under stress. There was a 67% correlation of her symptoms with the reflux expisodes. Esophageal manometery revealed a moderately low lower esophageal sphincter pressure. Esophageal contractions were normal. The patient was very interested in pursuing a surgical correction of her reflux symptoms and was referred to me.
She had a previous history of a right inguinal hernia repair with subsequent recurrence repaired with mesh. She subsequently developed chronic right groin pain. She underwent multiple procedures to deal with this including two re-explorations by two different surgeons, a ligation of the ileoinguinal nerve and finally a genitofemoral neurectomy which finally relieved her pain. I was able to discuss her past surgical history with one of her previous surgeons. He cautioned me about contemplating surgery in this patient given her past difficulty.
I ordered a video esophagram which showed normal esophageal contractility, no hiatal hernia and no evidence of reflux. There was delayed gastric emptying on this study noted. A nuclear medicine study confirmed this with a T1/2 of 150 minutes (normal < 90 minutes).
I told the patient that I would not recommend surgery for her symptoms given the poor gastric emptying. She elected to see another surgeon at another hospital. A laparoscopic Nissen fundiplication was performed in August. Postoperatively she developed severe gas bloat symptoms. She was reexplored in November and a laparoscopic pyloroplasty was performed. This did not improve her symptoms.
She now has severe postprandial bloating. She has been only able to tolerate a liquid diet. She cannot vomit or burp after developing her bloating symptoms. She has some dysphagia, but this seems relatively mild in relation to her bloating symptoms. She has no real history of constipation to suggest a generalized bowel motility disorder. She has no history of diabetes.
Repeat esophageal manometry showed a markedly elevated lower esohageal sphincter pressure of 49.6 mmHg. There was inadequate relaxation with a pressure of 16.6 mmHg during a swallow. EGD showed a large amount of retained gastric food despite an overnight fast. The pyloroplasty appeared widely patent. Gastric emptying study showed a T1/2 of 354 minutes.
The patient was reluctant to go to her last surgeon again and was referred back to my office for evaluation. I have told her that I would be again reluctant to consider surgical intervention at this point. She asked about esophageal dilatation, but I told her that I thought this would be a poor idea as long as she had the problem with her poor gastric emptying. She is desperate to be able to vomit or burp again. I would hate to have to consider a subtotal gastrectomy in this patient, but I am afraid that it may come to this point. In one of my elderly scleroderma patients, I have placed a continent Janeway type of gastrostomy along with a feeding jejunostomy for simultaneous decompression and enteral feeding as a palliative measure to prevent reflux. I would not want to subject someone so young to something like that.
I do not intend this post to be an indictment of laparoscopic Nissen’s. In properly selected individuals, they are some of the most grateful patients postoperatively that I have had to pleasure to see. It does point out the importance of proper patient selection.
What should or what could I do now to help this unfortunate patient? Any thoughts?