For patients without morbid obesity, the next decision point is determining the presence and size of a hiatal hernia. In patients with gastroparesis and GERD who only have a small type I hiatal hernia , the severity of gastroparesis needs to be determined based on gastric emptying study. Severity of delay is based on the four-hour retention value of the gastric emptying study: mild, 11–15% retention; moderate, 16–35% retention; and severe, >35% retention [9, 10]. For those with mild delayed gastric emptying, fundoplication alone may be sufficient and appropriate.

For patients with severe gastroparesis, GERD, and a small hiatal hernia, pyloroplasty in conjunction with a hiatal hernia repair and fundoplication has been recommended [11, 12]. In Masqusi and Velanovich’s study , patients with symptomatic GERD and objective findings by physiologic testing were offered antireflux surgery; a total of 369 patients underwent antireflux surgery, of which 9.5% who had delayed gastric emptying (defined as T _1/2 > 120 minutes) underwent pyloroplasty. Of those undergoing pyloroplasty, 80% reported significant improvement of bloating [12]. There is currently no consensus on the threshold at which to add pyloroplasty to a fundoplication for moderately delayed emptying. In our experience, antireflux operation alone for moderate delayed emptying has been successful and does not preempt pyloroplasty in the future, should it become necessary.

For patients with large hiatal hernias or paraesophageal hernias with delay in gastric emptying on a nuclear medicine study, we recommend performing a standard antireflux operation. Given that the stomach has been severely displaced into the chest, an aspect of gastric atony is present in patients with chronic paraesophageal hernias. Therefore, the recommendation is to first perform a paraesophageal hernia repair in standard fashion. Frequently, the repositioning of the stomach back into the abdomen, along with straightening the orientation of the stomach, is sufficient to treat any delayed gastric emptying (especially given the inaccuracy of a gastric emptying study in patients with paraesophageal hernias). We offer Nissen fundoplication to patients with normal esophageal body motility, whereas a Toupet fundoplication is offered to those with poor motility due to concerns that a full 360° wrap may increase the occurrence of dysphagia ; however, many studies have demonstrated that Nissen fundoplication does not increase the occurrence of dysphagia in patients with poor motility [13, 14]. Some surgeons prefer Toupet in the setting of delayed gastric emptying due to concerns about postoperative gas bloat.

It is also important to note that postoperative gastroparesis may also present after antireflux procedures in patients with large paraesophageal hernia and without preoperative gastroparesis. Nonoperative management of postoperative gastroparesis is recommended; however, if unsuccessful, pyloroplasty may be necessary [12]. Nonoperative management includes identifying trigger food and diet modifications accordingly, laxatives, prosecretory and promotility agents, antibiotics, behavior and psychotherapy, and/or alternative therapies (e.g., simethicone, charcoal, etc.) [8]. Refractory postfundoplication gastroparesis is defined as ongoing nausea, vomiting, bloating, and/or abdominal pain [8, 9]. Some studies have shown resolution of postfundoplication gastroparesis of about 90% at one year after surgery; therefore, if symptoms are refractory at one year after fundoplication, it is reasonable to consider performing a pyloroplasty [15–18]. However, important factors to consider in deciding on the timing of pyloroplasty include the severity of symptoms and the effects on quality of life.