Gastric ulceration after fundic wrapping. Vagal nerve entrapment, a possible causative factor

Abstract

Transabdominal fundoplication is an effective operation for control of gastroesophageal reflux in the majority of patients. The operation is, however, associated with several sell-documented early and late complications. Recently, a few reports have appeared describing benign gastric ulceration (GU) occurring from one month to several years postplication. The etiology of GU in this setting is unknown, but preexisting delayed gastric emptying, pyloric incompetence, faulty wrap construction, local ischemia, and trauma to the vagus nerves have been incriminated. During a recent seven-year period, five cases of GU have occurred among a series of 158 patients who underwent fundoplication. The cases are cited in detail, and the recent literature is reviewed. Discussion is addressed to the various proposed factors and combination of factors thought to contribute to GU. Suggestions are included for the preoperative evaluation of patients with gastroesophageal reflux as an aid to intraoperative management. As trauma to the vagus nerves has been frequently mentioned as a contributing factor to postplication ulcer, an operative technique is described in which the vagus nerves are isolated and protected from the fundic wrap.