Morbid Obesity, GERD, Gastroparesis and Type 2 Diabetes: What Do They Have in Common?

Surgical manipulation of the gastric fundus by resection, plication, invagination or bypass results in physiologic changes. These changes have immediate and significant therapeutic effect leading to improvement and sometimes cure of chronic progressive diseases like obesity, GERD, gastroparesis and type 2 diabetes. Indeed, the most effective and most reliable treatment for morbid obesity and type 2 diabetes is gastric fundus resection in the form of sleeve gastrectomy, or gastric fundus bypass in the form of Roux-en-Y gastric bypass surgery. Similarly, the best treatment for acid reflux disease is a 360 or 270-degree fundoplication. As for gastroparesis, I have had great success performing a longitudinal gastrectomy that preserves the gastric antrum and resects most of the gastric fundus to promote gastric emptying.

The oldest surgery performed on the gastric fundus to alter a pathophysiologic process was the Nissen fundoplication. Dr Nissen came across his procedure by serendipity more than 50 years ago. It is thought that wrapping the gastric fundus around the lower esophagus, reinforces the lower esophageal sphincter leading to acid reflux control. However, we know now that acid reflux disease is a multifactorial problem and the exact mechanism of Nissen fundoplication is not well understood. Rather than increasing the resting lower esophageal sphincter pressure, Nissen fundoplication alters gastric motility and emptying patterns favoring cephalad movement of gastric content away from the gastro-esophageal junction. A short and floppy fundoplication that avoids constricting the lower esophageal sphincter is currently the accepted surgical standard. The purpose of fundoplication surgery is to reconfigure the gastric fundus anatomy and wall compliance rather than reinforce the lower esophageal sphincter. Similarly, gastric fundus resection in sleeve gastrectomy results in increased gastric emptying and altered gastro-intestinal neuro-hormonal signaling. Such physiologic changes are more important than mechanical restriction to achieve significant and durable weight loss as well as type 2 diabetes remission. Few years ago, I published a case report about a type 2 diabetes patient with severe and medically refractory gastroparesis. The patient had been constantly vomiting and had lost significant amount of weight. He was TPN dependent to meet his calorie needs and replace his electrolytes. His stomach and duodenum were dilated. I performed a longitudinal gastrectomy that preserved the antrum. Due to his malnutrition, I elected to preserve some of the gastric fundus and body. I also performed a side to side duodeno-jejunostomy to decompress the dilated duodenum. Patient’s gastroparesis related symptoms immediately resolved and tolerated liquid diet on day one after surgery. His diet was rapidly advanced to regular food and 4 years following surgery the patient remains asymptomatic. Interestingly, the patient type 2 diabetes of 15 years resolved and his blood sugar normalized as he was regaining all his lost weight. The case clearly illustrated the relationship between gastric fundus surgery and gastric emptying and their effect on type 2 diabetes remission.

Gastric fundus anatomy and physiology plays a crucial role in the pathophysiology of many diseases that have reached an epidemic level in our society. Gastric fundus surgery alters gastro-intestinal motility patterns leading to improvement and most often remission of obesity, GERD, type 2 diabetes and gastroparesis.

Laparoscopic longitudinal gastrectomy and duodenojejunostomy for treatment of diabetic gastroparesis. Surg Obes Relat Dis. 2012 Nov-Dec;8(6):811-3.
Darido E, Farrell TM.