S2930 Gastric Ischemia: A Late Complication of Heller Myotomy and Dor Fundoplication

Abstract

INTRODUCTION: Gastric ischemia is a rare disorder due to the generous vascular supply of the stomach It most commonly is a consequence of severe sepsis, shock, or splanchnic vessel hypoperfusion In extremely rare cases, gas bloat syndrome may cause severe gastric dilation to the extent of causing gastric ischemia Gas bloat syndrome is a known complication of gastric fundoplication in which gastric dilation occurs from the impaired expulsion of trapped air from belching due to the compressive gastric wrap at the distal esophagus Partial fundoplication has led to decrease in the incidence of gas bloat syndrome as compared to the complete technique We present a patient with a history of achalasia treated with Heller myotomy and Dor fundoplication that developed a large gastric ischemic ulcer as a late complication CASE DESCRIPTION/METHODS: An 82-year-old female with history of peptic ulcer disease, gastroparesis, and type II achalasia presented to the hospital with coffee-ground emesis, dysphagia, epigastric pain, and early satiety Two years prior she underwent Heller myotomy and Dor fundoplication and has since complained of these progressively worsening symptoms On presentation, the patient's hemoglobin was 9 3 gm/dL and a pantoprazole drip was initiated CT abdomen revealed severe gastric wall thickening with no gastric volvulus The patient underwent an EGD the following day which revealed inflamed, necrotic, and ulcerated mucosa involving the fundus, gastric body, and antrum Biopsy confirmed ischemic features Doppler ultrasound of the abdomen ruled out an occlusive vascular disease Patients symptoms continued to improve over the next 48 hours and was discharged on pantoprazole, and a short course of a prokinetic and simethicone At discharge, a repeat EGD with Endoflip technique was scheduled at 8 weeks to evaluate the lower esophageal sphincter distensibility Unfortunately, this procedure was delayed due to the COVID pandemic and results are not available at the time of this abstract DISCUSSION: Failure to recognize gas bloat syndrome as a complication after fundoplication can lead to severe gastric distention and ischemia, especially if confounded with emptying disorders such as gastroparesis Endoflip is a promising tool to evaluate the distensibility of the lower esophageal sphincter Further research is needed to validate the use of this technique to evaluate the response to fundoplication and rule out severe tightening of the gastroesophageal junction (Figure Presented)