S6423 Severe Gas Bloat Syndrome and Gastric Necrosis: A Rare Complication of Toupet Fundoplication

Introduction: Laparoscopic fundoplication is a commonly utilized surgical technique in the management of gastroesophageal reflux disease (GERD), with Nissen (360°) and Toupet (270° partial posterior) techniques typically used. Toupet fundoplication is often preferred for its lower rates of postoperative dysphagia and gas-related complications. Gas bloat syndrome (GBS), characterized by bloating, epigastric fullness, and flatulence, is more frequently seen after Nissen fundoplication but is an exceedingly rare complication following Toupet procedures. Severe GBS can result in acute gastric dilation and ischemia, which carries a mortality rate of up to 73%. We present a rare case of GBS complicated by gastric necrosis following Toupet fundoplication. Case Description/Methods: A 42-year-old man with a history of Toupet fundoplication presented with acute abdominal pain. Computed tomography (CT) imaging revealed marked gastric distention without evidence of perforation. Esophagogastroduodenoscopy (EGD) showed copious gastric fluid and particulate matter requiring prolonged lavage. Endoscopic inspection revealed black, necrotic-appearing mucosa involving 30–40% of the fundus, cardia, and lesser curvature, with surrounding erythematous but viable tissue. No perforation was seen, and the fundoplication wrap appeared intact and perfused. Due to concerns for ischemia, biopsies were deferred, and a nasogastric tube was endoscopically placed for decompression. On repeat EGD the following day, significant mucosal improvement was observed, with residual erythema and granularity suggestive of reperfusion. Persistent debris in the antrum and pylorus suggested possible underlying gastroparesis, so 200 units of botulinum toxin were injected into the pylorus to aid with this. The patient improved and was discharged 7 days later without complications. Discussion: Even though GBS is a complication that is more commonly associated with Nissen fundoplication, it is important to remain vigilant in patients that undergo Toupet procedures as well. GBS is still a rare, potential complication that can lead to severe outcomes, such as gastric necrosis. Early recognition of this condition and prompt decompression are important in order to prevent irreversible injury. In cases complicated by delayed gastric emptying, clinicians can consider pyloric botulinum toxin injections or performing gastric emptying scans prior to surgery.