Completion gastrectomy for refractory gastroparesis following surgery for peptic ulcer disease. Long-term follow-up with subjective and objective parameters

United European Gastroenterology (UEG) and European Society for Neurogastroenterology and Motility (ESNM) consensus on gastroparesis

BACKGROUND

Gastroparesis is a condition characterized by epigastric symptoms and delayed gastric emptying (GE) rate in the absence of any mechanical obstruction. The condition is challenging in clinical practice by the lack of guidance concerning diagnosis and management of gastroparesis.

METHODS

A Delphi consensus was undertaken by 40 experts from 19 European countries who conducted a literature summary and voting process on 89 statements. Quality of evidence was evaluated using grading of recommendations assessment, development, and evaluation criteria. Consensus (defined as ≥80% agreement) was reached for 25 statements.

RESULTS

The European consensus defined gastroparesis as the presence of symptoms associated with delayed GE in the absence of mechanical obstruction. Nausea and vomiting were identified as cardinal symptoms, with often coexisting postprandial distress syndrome symptoms of dyspepsia. The true epidemiology of gastroparesis is not known in detail, but diabetes, gastric surgery, certain neurological and connective tissue diseases, and the use of certain drugs recognized as risk factors. While the panel agreed that severely impaired gastric motor function is present in these patients, there was no consensus on underlying pathophysiology. The panel agreed that an upper endoscopy and a GE test are required for diagnosis. Only dietary therapy, dopamine-2 antagonists and 5-HT₄ receptor agonists were considered appropriate therapies, in addition to nutritional support in case of severe weight loss. No consensus was reached on the use of proton pump inhibitors, other classes of antiemetics or prokinetics, neuromodulators, complimentary, psychological, or more invasive therapies. Finally, there was consensus that gastroparesis adversely impacts on quality of life and healthcare costs and that the long-term prognosis of gastroparesis depends on the cause.

CONCLUSIONS AND INFERENCES

A multinational group of European experts summarized the current state of consensus on definition, symptom characteristics, pathophysiology, diagnosis, and management of gastroparesis.

United European Gastroenterology (UEG) and European Society for Neurogastroenterology and Motility (ESNM) consensus on gastroparesis

Background

Gastroparesis is a condition characterized by epigastric symptoms and delayed gastric emptying (GE) rate in the absence of any mechanical obstruction. The condition is challenging in clinical practice by the lack of guidance concerning diagnosis and management of gastroparesis.

Methods

A Delphi consensus was undertaken by 40 experts from 19 European countries who conducted a literature summary and voting process on 89 statements. Quality of evidence was evaluated using grading of recommendations assessment, development, and evaluation criteria. Consensus (defined as ≥80% agreement) was reached for 25 statements.

Results

The European consensus defined gastroparesis as the presence of symptoms associated with delayed GE in the absence of mechanical obstruction. Nausea and vomiting were identified as cardinal symptoms, with often coexisting postprandial distress syndrome symptoms of dyspepsia. The true epidemiology of gastroparesis is not known in detail, but diabetes, gastric surgery, certain neurological and connective tissue diseases, and the use of certain drugs recognized as risk factors. While the panel agreed that severely impaired gastric motor function is present in these patients, there was no consensus on underlying pathophysiology. The panel agreed that an upper endoscopy and a GE test are required for diagnosis. Only dietary therapy, dopamine‐2 antagonists and 5‐HT₄ receptor agonists were considered appropriate therapies, in addition to nutritional support in case of severe weight loss. No consensus was reached on the use of proton pump inhibitors, other classes of antiemetics or prokinetics, neuromodulators, complimentary, psychological, or more invasive therapies. Finally, there was consensus that gastroparesis adversely impacts on quality of life and healthcare costs and that the long‐term prognosis of gastroparesis depends on the cause.

Conclusions and Inferences

A multinational group of European experts summarized the current state of consensus on definition, symptom characteristics, pathophysiology, diagnosis, and management of gastroparesis.

Current knowledge

The epidemiology of gastroparesis is not well known.

Diagnosis and treatment of gastroparesis is challenging due to uncertainties in definition and optimal therapeutic approach.

What is new here

A Delphi panel consisting of 40 experts from 19 European countries established the level of consensus on 89 statements regarding gastroparesis.

The statements reaching consensus serve to guide clinicians in recognizing, diagnosing and treating gastroparesis in clinical practice.

The statements without consensus identify areas in need of future research.

Long-limb Roux-en-Y Reconstruction after Subtotal Gastrectomy to Treat Severe Diabetic Gastroparesis

The role of surgical intervention in patients with diabetic gastroparesis is unclear. We report a case of a 37-year-old man with a history of recurrent episodes of vomiting and long-standing type 2 diabetes mellitus. Esophagogastroduodenoscopy did not reveal any findings of reflux esophagitis or obstructive lesions. A gastric emptying time scan showed prolonged gastric emptying half-time (344 minutes) indicating delayed gastric emptying. Laboratory tests revealed elevated fasting serum glucose and glycosylated hemoglobin (HbA1c, 12.9%) and normal fasting C-peptide and insulin levels. We performed Roux-en-Y reconstruction after subtotal gastrectomy to treat gastroparesis and improve glycemic control, and the patient showed complete resolution of gastrointestinal symptoms postoperatively. Barium swallow test and gastric emptying time scan performed at follow-up revealed regular progression of barium and normal gastric emptying. Three months postoperatively, his fasting serum glucose level was within normal limits without the administration of insulin or oral antidiabetic drugs with a reduced HbA1c level (6.9%). Long-limb Roux-en-Y reconstruction after subtotal gastrectomy may be useful to treat severe diabetic gastroparesis by improving gastric emptying and glycemic control.

Gastrectomy versus stomach left in situ with Roux-en-Y reconstruction for the treatment of gastroparesis

BACKGROUND

Gastroparesis is a debilitating functional disorder of the stomach marked by delayed gastric emptying in the absence of mechanical obstruction. Patients with severe, refractory symptoms may ultimately be managed with Roux-en-Y reconstruction; however, it is unclear whether the stomach should be left in situ, similar to a conventional gastric bypass, or resected as in gastrectomy.

METHODS

All patients undergoing Roux-en-Y for the treatment of gastroparesis (GP) at our institution from September 2010 through March 2018 were retrospectively reviewed. Patients with prior gastric resection or whose primary operative indication was not gastroparesis were excluded from analysis.

RESULTS

Twenty-six patients underwent Roux-en-Y with stomach left in situ (RY-SIS) and twenty-seven patients underwent gastrectomy with Roux-en-Y reconstruction during the study period. The mean age was 49.7 years in the RY-SIS cohort and 48.5 years in the gastrectomy cohort. Etiology of GP was similar between the two cohorts. Patients undergoing gastrectomy were more likely to have previous interventions for GP (63.0% vs. 26.9%). RY-SIS was associated with a shorter operative time (155 vs. 223 min), less blood loss (24 vs. 130 mL), and shorter length of stay (4.0 vs. 7.2 days). Twelve patients (44.4%) had complications within 30 days following gastrectomy compared to two patients (7.7%) following RY-SIS (p = 0.001). Patients in the RY-SIS cohort were more likely to require further subsequent surgical intervention for GP (23.1% vs. 3.7%, p = 0.04). At last follow-up, there were no differences in reported GP symptoms or symptom scoring.

CONCLUSIONS

Gastrectomy was associated with greater perioperative morbidity compared to leaving the stomach in situ. Symptomatic improvement at intermediate follow-up was equivalent following either procedure. However, patients undergoing RY-SIS were more likely to require subsequent surgical intervention, suggesting that gastrectomy may be a more definitive operation for the management of medically refractory gastroparesis.

Per-Oral Pyloromyotomy (POP) for Medically Refractory Post-Surgical Gastroparesis

BACKGROUND

Post-surgical gastroparesis (psGP) is putatively related to vagal denervation from either therapeutic transection or inadvertent injury. Here, we present a series of patients undergoing endoscopic per-oral pyloromyotomy (POP) as a treatment for medically refractory psGP.

METHODS

Patients identified from a prospectively maintained database of patients undergoing POP procedures at our institution from January 2016 to January 2018 were included. Surgical history, symptom scores, and gastric emptying studies before and 3 months after POP were additionally recorded.

RESULTS

During the study period, 177 POP procedures were performed, of which 38 (21.5%) were for psGP. The study cohort was 84.2% female with a mean body mass index of 27.6 kg/m² and mean age of 55.2 years. Common comorbidities included hypertension (34.2%), depression (31.6%), and gastroesophageal reflux disease (28.9%). Hiatal/paraesophageal hernia repair (39.5%) or fundoplication (36.8%) preceded psGP diagnosis most often. The mean operative time was 30 ± 20 min. There were no intraoperative complications. Mean postoperative length of stay was 1.2 days. There were two readmissions within 30 days, one for melena and one for dehydration. The mean improvement in total Gastroparesis Symptom Index Score was 1.29 (p = 0.0002). The mean 4-h gastric retention improved from a pre-POP mean of 46.4 to 17.9% post-POP. Normal gastric emptying was noted in 50% of subjects with available follow-up imaging.

CONCLUSION

POP is a safe and effective endoscopic therapy for patients with psGP. POP should be considered a reasonable first-line option for patients with medically refractory psGP and may allow stomach preservation.

Effectiveness and feasibility of robotic gastric neurostimulator placement in patients with refractory gastroparesis

Gastric neurostimulation (GNS) with Enterra^® therapy device (Medtronic, Minneapolis, MN) appears as the last resort for patients with refractory gastroparesis. Currently, the device has Humanitarian Use status by Food and Drug Administration, thereby requiring further investigation. We aim to describe its feasibility and clinical outcomes using robotic technique. From June 2014 to September 2016, 15 consecutive patients underwent robotic insertion of Enterra^® device. Patient demographics, comorbidities, and clinical outcomes including mortality, length of stay, readmission rates, reoperation and complications were retrospectively collected. Patients were also assessed based on a validated 14-point questionnaire regarding satisfaction with the operation, quality of life and symptomatic relief. Mean age was 41.6 years ± 13.8 and there were 11 females (73.3%). No mortality was reported. The annual hospital admissions were reduced after GNS (2.5 ± 4.1 vs. 3.6 ± 4.4, p = 0.004). The frequency of bloating (p = 0.029) and severity of emesis (p = 0.038), early satiety (p = 0.042) and bloating (p = 0.031) were reduced after GNS. The severity and frequency total scores were also improved after GNS (12.6 ± 1.4 vs. 18.1 ± 2.7, p = 0.008 and 12.9 ± 2.2 vs. 16.1 ± 1.1, p = 0.016, respectively). This is the first report describing the clinical experience with robotic insertion of GNS device. This approach is safe and feasible and seems to have similar long-term outcomes as laparoscopic technique. Potential advantages to robotic technique include enhanced dexterity and suturing of the device within gastric wall. Further experience with large prospective studies and randomized clinical trials may be warranted.

Surgical approaches to treatment of gastroparesis: gastric electrical stimulation, pyloroplasty, total gastrectomy and enteral feeding tubes

Gastric electrical stimulation (GES) is neurostimulation; its mechanism of action is affecting central control of nausea and vomiting and enhancing vagal function. GES is a powerful antiemetic available for patients with refractory symptoms of nausea and vomiting from gastroparesis of idiopathic and diabetic causes. GES is not indicated as a way of reducing abdominal pain in gastroparetic patients. The need for introducing a jejunal feeding tube means intensive medical therapies are failing, and is an indication for the implantation of the GES system, which should always be accompanied by a pyloroplasty to guarantee accelerated gastric emptying.

[Gastroparesis: pathophysiology and management]

The prevalence of gastroparesis is increasing. Diabetes mellitus and sequelae of œsogastric surgery are the two main causes of gastroparesis. In some patients, gastroparesis seems a postinfectious disease after its sudden onset after a viral infection. In about one third of the patients, gastroparesis is considered as idiopathic. In diabetic patients, gastroparesis impairs glycaemic control. Due to the low positive predictive value of symptoms, a gastric emptying study is often necessary to confirm a suspected diagnosis of gastroparesis. The symptomatic efficacy of erythromycin is higher than that of other prokinetics. This efficacy is higher when erythromycin is given intravenously. Hyperglycaemia impairs this symptomatic effect. Due to a tachyphylaxis phenomenon, the clinical effect of erythromycin decreases with the duration of treatment. In refractory gastroperis, either duodenal or jejunal enteral feeding, or high-frequency gastric electrical stimulation are possible therapeutic options while endoscopic alternatives (intrapyloric botulinum injection or pyloric balloon dilation) give unsatisfactory results.

Total gastrectomy for benign diseases: a two-case report and literature review

Total gastrectomy may be indicated in treating extensive stomach malignancies. It is also the procedure of choice in controlling the intractable ulcer diathesis associated with non-beta islet cell tumors of the pancreas when pancreatic tumor or metastases cannot be controlled medically. Here we report two patients with benign gastric diseases, who were treated for total gastrectomy. In combination with our experiences and relative literatures, the indications of total gastrectomy for benign disease were summarized.

Results of completion gastrectomies in 44 patients with postsurgical gastric atony

INTRODUCTION

Postsurgical gastric atony occurs infrequently after gastric surgery. However, the symptoms are disabling and refractory to medical management. The only effective treatment is completion gastrectomy. A few studies have examined in detail the long-term results of this radical procedure.

METHODS

From 1988 through 2007, 44 patients (84% female, 16% male) underwent near-total or total completion gastrectomies for refractory postsurgical gastric atony. The average age was 52 (range 32-72). Gastric atony was documented using radionuclide solid food emptying studies. Charts were reviewed retrospectively to identify preoperative symptoms and long-term postoperative function, and the patients were contacted by phone to evaluate their current level of function.

RESULTS

Of the original 44 patients, 66% (n = 29) were evaluated postoperatively at a mean of 5.6 + 4.5 years (range 0.5-15.0 years). Fourteen patients (32%) had died, and seven (16%) were lost to follow-up. Most common presenting symptoms were abdominal pain (98%), vomiting (98%), nausea (77%), diet limitation (75%), heartburn (64%), and weight loss (59%, average = 19% of BW). Postoperative complications occurred in 36% (n = 16), most commonly bowel obstruction (11%), anastomotic stricture (9%), and anastomotic leak (7%), and there was one perioperative death. At last follow-up, there were significant improvements in abdominal pain (97% to 59%, p < 0.001), vomiting (97% to 31%, p < 0.001), nausea (86% to 45%, p < 0.001), and diet limited to liquids or nothing at all (57% to 7%, p < 0.001). Some symptoms were more common postoperatively, including early satiety (24% to 89%, p < 0.001), and postprandial fullness (10% to 72%, p < 0.001). Average BMI at the time of surgery and at last follow-up were 23 and 21, respectively. Osteoporosis was diagnosed pre- and postoperatively in 17% and 67% of patients, respectively (p < 0.001). Seventy-eight percent of patients stated that they were in better health after surgery, while 17% were neutral, and 6% stated that they were worse off. Mean satisfaction with surgery was 4.7 (1-5 Likert scale).

CONCLUSION

Completion gastrectomies in this patient population resulted in significant improvements in abdominal pain, vomiting, nausea, and severe diet limitations. Most patients, however, have significant ongoing gastrointestinal complaints, and the incidence of osteoporosis is high. Patient satisfaction is high; about 78% of patients believed their health status is improved. We believe these data support the selective use of completion gastrectomies in patients with severe postsurgical gastroparesis.

Treatment of refractory gastroparesis: gastric and jejunal tubes, botox, gastric electrical stimulation, and surgery

Refractory gastroparesis is a challenging disorder for gastroenterologists, internists, surgeons, and all health care professionals involved in the care of these patients. It should be managed by a stepwise algorithm beginning with dietary modifications, then prokinetic and antiemetic medications, measures to control pain and address psychological issues, and endoscopic or surgical options in selected patients, including placement of feeding jejunostomy tubes.

Small bowel bypass as treatment for functional gastric obstruction

Multiple bariatric operations performed on the same patient can cause loss of normal peristaltic function of the stomach. Bariatric revisions, especially when combined with previous truncal vagotomy, can lead to functional gastric obstruction. These patients complain of severe nausea and intractable vomiting. This can cause excessive weight loss and malnutrition, requiring at times total parenteral nutrition (TPN) or forms of enteral feeding. These patients frequently require a total or subtotal gastric resection with an esophago-jejunal anastomosis to relieve symptoms. We present two patients with a functional gastric obstruction treated by a small bowel bypass, which successfully relieved all symptoms of obstruction and allowed normal food intake.

Refractory gastroparesis after Roux-en-Y gastric bypass: surgical treatment with implantable pacemaker

BACKGROUND

Gastroparesis is a rare complication of Roux-en-Y gastric bypass. We evaluate the role of gastric electrical stimulation in medically refractory gastroparesis.

METHODS

Patients with refractory gastroparesis after gastric bypass for morbid obesity were studied. After behavioral and anatomic problems were ruled out, the diagnosis of disordered gastric emptying was confirmed by radionuclide gastric emptying. Temporary endoscopic stimulation was used first to assess response before implanting a permanent device.

RESULTS

Six patients, all women with mean age of 42 years, were identified. Two patients ultimately had reversal of their surgery with gastro-gastrostomy, while another had a total gastrectomy with persistence of symptoms in all three. Five of the patients evaluated had insertion of a permanent gastric pacemaker, with pacing lead implanted on the gastric pouch (2), the antrum of the reconstructed stomach (1), or the proximal Roux limb (2). Nausea and emesis improved significantly postoperatively; mean total symptom score decreased from 15 to 11 out of 20. There was also a persistent improvement in gastric emptying postoperatively based on radionuclide testing.

CONCLUSION

If medical therapy fails, electrical stimulation is a viable option in selected patients with gastroparesis symptoms complicating gastric bypass and should be considered in lieu of reversal surgery or gastrectomy.

Clinical application prospects of gastric pacing for treating postoperative gastric motility disorders

Similar to the heartbeat, gastric peristalsis is regulated by an electrical rhythm generated by a pacemaker. Thus, electrical dysrhythmia of gastric slow waves will inevitably affect gastric peristalsis and emptying. The recurrence of postoperative gastroparesis is thereby closely related to the abnormalities of electrical dysrhythmia and ectopic pacemakers, resulting in postoperatively persistent gastric motility disorders in some severe cases, despite the use of prokinetic and antiemetic drugs. Recent studies have demonstrated that gastric pacing, analogous to pacing the human heart, is an attractive and promising therapy that is both feasible and safe. Gastric pacing has been shown to be strikingly effective in normalizing gastric dysrhythmia, increasing the activity of the gastric slow wave and thereby prompting gastric dynamia and emptying. Furthermore, the long-term utilization of gastric pacing can (i) relieve patients from clinical symptoms, such as nausea and vomiting; (ii) release patients with severe postoperative gastroparesis from relying on prokinetic drugs and the jejunal feeding tube; (iii) return patients to normal oral nutritional intake and provide a more satisfactory nutritional status and most importantly; and (iv) give patients a better quality of life. Overall, research focused on gastric pacing has demonstrated excellent prospects for clinical application in the treatment of postoperative gastroparesis disorders, especially for those unresponsive to prokinetic drugs.

Laparoscopic Insertion of Gastric Electrodes for Electrical Stimulation

Gastric electrical stimulation can provide symptomatic relief for patients with refractory gastroparesis. Traditionally, these wires are placed through a midline laparotomy. This paper describes and illustrates, in detail, the laparoscopic technique for successful implantation. Thirty-one consecutive patients from October 2003 to March 2005 underwent laparoscopic insertion of gastric stimulating wires for gastroparesis. Twenty-six patients were female. Four laparoscopic ports were used to insert a pair of electrodes. Anterior, cephalad retraction of the gastric wall is critical for accurate seromuscular placement of gastric leads. Intraoperative endoscopy was used to verify the seromuscular placement of the leads. Both leads were secured to a subcutaneous generator and electrical parameters were immediately established in the operating room. Patient demographics, operative details, and postoperative morbidities were recorded. All procedures were completed laparoscopically. The mean operative time was 114.4 +/- 20.9 minutes (range, 95-140). No perioperative mortality occurred. Two patients developed cellulitis at the generator site postoperatively and oral antibiotics were prescribed for one week postoperatively. No hardware was removed. Two patients had their generators repositioned due to pain at the pocket site. Gastric electrical stimulation is a novel treatment modality for patients with refractory gastroparesis and can be accomplished safely via laparoscopy. Laparoscopic insertion is successful even in patients with prior surgery and intact gastrointestinal tubes. Long-term follow-up and the current prospective multicenter trial continue to assess the efficacy of this treatment modality.

Treatment of gastroparesis: a multidisciplinary clinical review

This clinical review on the treatment of patients with gastroparesis is a consensus document developed by the American Motility Society Task Force on Gastroparesis. It is a multidisciplinary effort with input from gastroenterologists and other specialists who are involved in the care of patients with gastroparesis. To provide practical guidelines for treatment, this document covers results of published research studies in the literature and areas developed by consensus agreement where clinical research trials remain lacking in the field of gastroparesis.

Pilot Study on Gastric Electrical Stimulation on Surgery-associated Gastroparesis: Long-term Outcome

OBJECTIVES

Patients with postgastric surgery gastroparesis are often unresponsive to conventional medical therapy. Gastric electrical stimulation (GES) with the use of high-frequency and low-energy neural stimulation is an approved technique for patients with idiopathic and diabetic gastroparesis.

METHODS

We hypothesized that GES would improve symptoms, health resource utilization, and gastric emptying in six patients with postsurgical gastroparesis from a variety of surgical procedures. Patients were evaluated by means of the following criteria: symptoms, health-related quality of life, and gastric emptying tests at baseline over time.

RESULTS

All patients noted improvements after device implantation for up to 46 months: the frequency score for weekly vomiting went from a baseline of 3.2 down to 0.4 immediately after treatment before settling at 1.4 by the long-term follow up. Total gastrointestinal symptom score went from 36.5 at baseline down to 12.3 before settling at 20.5 at long-term follow up. Improvements were also seen in health-related quality of life and solid and liquid gastric emptying.

CONCLUSIONS

We conclude that GES is associated with clinical improvements in this group of patients with either postsurgical or surgery-associated gastroparesis. This pilot study with long-term outcomes offers evidence for a new therapy for otherwise refractory patients with gastroparesis associated with previous surgery.

Clinical response to gastric electrical stimulation in patients with postsurgical gastroparesis

BACKGROUND & AIMS

The aim of this study was to report the long-term clinical response to high-frequency gastric electrical stimulation (GES) in 16 patients with postsurgical gastroparesis who failed standard medical therapy.

METHODS

Clinical data collected at baseline and after 6 and 12 months of GES included (1) severity and frequency of 6 upper gastrointestinal (GI) symptoms by using a 5-point symptom interview questionnaire and total symptom score, (2) health-related quality of life including physical composite score and mental composite score, (3) 4-hour standardized gastric emptying of a solid meal by scintigraphy, and (4) nutritional status.

RESULTS

The severity and frequency of all 6 upper GI symptoms, total symptom score, physical composite score, and mental composite score were significantly improved after 6 months and sustained at 12 months ( P < .05). All patients had delayed gastric emptying at baseline. Gastric emptying was not significantly faster at 12 months, although 3 normalized. At implantation, 7 of 16 patients required nutritional support with a feeding jejunostomy tube; after GES, 4 were able to discontinue jejunal feeding. The mean number of hospitalization days was significantly reduced by a mean 25 days compared with the prior year. One patient had the device removed after 12 months because of infection around the pulse generator.

CONCLUSIONS

Long-term GES significantly improved upper GI symptoms, quality of life, the nutritional status, and hospitalization requirements of patients with postsurgical gastroparesis. Although vagal nerve damage or disruption was part of the underlying pathophysiology, GES therapy was still effective and is a potential treatment option for the long-term management of postsurgical gastroparesis. A controlled clinical trial of GES for PSG patients (who are refractory to medical therapy) is indicated given these encouraging results.

American Gastroenterological Association technical review on the diagnosis and treatment of gastroparesis

This literature review and the recommendations herein were prepared for the American Gastroenterological Association Clinical Practice Committee. The paper was approved by the Committee on May 16, 2004, and by the AGA Governing Board on September 23, 2004.

Treatment of gastroparesis

Gastroparesis is a condition of impaired gastric motility that can be chronic and result in decreased quality of life and complete disability. Once the diagnosis of gastroparesis is established, the clinician's attention should immediately focus on restoring nutritional status, providing symptomatic relief from nausea and vomiting, and improving gastric motility. Combination therapy is the rule rather than the exception, and most patients require multiple prokinetic and antiemetic modalities for adequate symptom relief. Currently available medications are often inadequate to achieve therapeutic goals, and newer modalities, such as gastric electrical stimulation, which has been shown to decrease symptoms and improve quality of life, should be employed at a low threshold. Several novel therapeutic options are under investigation and may also become part of the routine treatment of gastroparesis.

A systematic review of surgical therapy for gastroparesis

Gastroparesis is characterized by delayed gastric emptying in the absence of obstruction. Common symptoms include nausea, vomiting, and abdominal pain. Severe gastroparesis might result in recurrent hospitalizations, malnutrition, and significant mortality. Patients failing medical therapy are often considered for a variety of surgical interventions, the efficacy of which is not well studied. This review summarizes available literature on surgical interventions in gastroparesis. A MEDLINE search for the period from 1966 to 2002 was performed to identify all English language literature regarding surgical interventions in gastroparesis. Therapies reviewed were gastrostomy, jejunostomy, gastric pacing/stimulation, and gastrectomy or surgical drainage procedures. Candidate studies involved human subjects and included surgical series or trials. The search was conducted independently by two authors and discrepancies resolved by consensus opinion. Seventeen articles met inclusion criteria. These included series reporting on gastrostomy (2), jejunostomy (3), gastric stimulation (2), and gastrectomy for postsurgical (6), diabetic (3), and idiopathic (1) gastroparesis. All trials were unblinded, uncontrolled case series or retrospective reviews. Methodologic differences did not allow for pooled analysis. Completion gastrectomy seems to provide symptom relief in postsurgical gastroparesis. Benefits of gastric surgery for other forms of gastroparesis are not adequately studied. Gastrostomy might provide symptom improvement, but only 26 subjects in two trials were evaluable. Jejunostomy improved symptoms and nutrition in 32 evaluable subjects in three trials but had significant complications. Gastric neurostimulation improves symptoms of nausea and vomiting, but therapeutic gain beyond placebo has not been demonstrated. Limited data exist concerning surgical therapies of gastroparesis. Completion gastrectomy seems effective for postsurgical gastroparesis, but a cautious approach is warranted before surgical therapies in diabetic or idiopathic gastroparesis are used.

Gastric electrical stimulation for medically refractory gastroparesis

BACKGROUND & AIMS

This study investigated the efficacy of gastric electrical stimulation for the treatment of symptomatic gastroparesis unresponsive to standard medical therapy.

METHODS

Thirty-three patients with chronic gastroparesis (17 diabetic and 16 idiopathic) received continuous high-frequency/low-energy gastric electrical stimulation via electrodes in the muscle wall of the antrum connected to a neurostimulator in an abdominal wall pocket. After implantation, patients were randomized in a double-blind crossover design to stimulation ON or OFF for 1-month periods. The blind was then broken, and all patients were programmed to stimulation ON and evaluated at 6 and 12 months. Outcome measures were vomiting frequency, preference for ON or OFF, upper gastrointestinal tract symptoms, quality of life, gastric emptying, and adverse events.

RESULTS

In the double-blind portion of the study, self-reported vomiting frequency was significantly reduced in the ON vs. OFF period (P < 0.05) and this symptomatic improvement was consistent with the significant patient preference (P < 0.05) for the ON vs. OFF period determined before breaking the blind. In the unblinded portion of the study, vomiting frequency decreased significantly (P < 0.05) at 6 and 12 months. Scores for symptom severity and quality of life significantly improved (P < 0.05) at 6 and 12 months, whereas gastric emptying was only modestly accelerated. Five patients had their gastric electrical stimulation system explanted or revised because of infection or other complications.

CONCLUSIONS

High-frequency/low-energy gastric electrical stimulation significantly decreased vomiting frequency and gastrointestinal symptoms and improved quality of life in patients with severe gastroparesis.

Gastric pacing is a new surgical treatment for gastroparesis

BACKGROUND

Gastroparesis is a chronic gastric motility disorder affecting mostly young and middle-aged women who present with nausea, abdominal pain, early satiety, vomiting, fullness, and bloating.

METHODS

From April 1998 to September 2000, 25 patients underwent gastric pacemaker placement. All had documented delayed gastric emptying by a radionucleotide study. Nineteen patients had diabetic gastroparesis, 3 had developed postsurgical gastroparesis, and 3 had idiopathic gastroparesis. Baseline and postoperative follow-ups were done by a self-administered questionnaire on which the patients rated the severity and frequency of nausea and vomiting. Gastric emptying times were also followed up using a radionucleotide technique.

RESULTS

Both the severity and frequency of nausea and vomiting improved significantly at 3 months and was sustained for 12 months. Gastric emptying time was also numerically faster over the 12-month period. Three of the devices have been removed. One patient died of causes unrelated to the pacemaker 10 months postoperatively.

CONCLUSIONS

After placement of the gastric pacemaker, patients rated significantly fewer symptoms and had a modest acceleration of gastric emptying.

Management of the patient with gastroparesis

Gastroparesis may be related to a variety of underlying disorders, but management options are fairly universal. Dietary measures and pharmacologic agents, primarily in the form of prokinetic medications, form the foundation of standard management. Some patients will have refractory symptoms and alternative dosing schemes or drug combinations may be used. An occasional patient will still require venting gastrostomy and/or jejunal feeding. This review addresses the standard dietary and pharmacologic approaches to gastroparesis, as well as issues pertaining to gastrostomy/jejunostomy tubes and to surgical options for refractory cases. Finally, experimental agents and techniques, such as gastric pacing, will be discussed.

Standard Roux-en-Y gastrojejunostomy vs. "uncut" Roux-en-Y gastrojejunostomy: a matched cohort study

Roux-en-Y gastrojejunostomy is a common method of reconstruction after subtotal gastrectomy. Maintaining myoneural continuity has been proposed to decrease the incidence of Roux stasis syndrome, with an "uncut" Roux-en-Y reconstruction. The aim of our study was to compare the clinical results in patients who have undergone uncut Roux-en-Y gastrojejunostomy with those in patients who have undergone a standard Roux-en-Y gastrojejunostomy. Eleven patients underwent gastrectomy and uncut Roux-en-Y gastrojejunostomy and were compared with a cohort of 14 patients who underwent gastrectomy and standard Roux-en-Y gastrojejunostomy. Patients were contacted and charts were reviewed for Visick grade, early and late morbidity and mortality, and incidence of staple line dehiscence. Early postoperative morbidity was 18% in patients undergoing uncut Roux gastrojejunostomy and 28% in patients undergoing standard Roux reconstruction. There were no early postoperative deaths in either group. In the patients undergoing the uncut Roux procedure, no cases of staple line dehiscence were detected clinically (mean follow-up 9 months, range 1 to 48 months). Visick grade improved following the uncut Roux procedure, but changed little after standard Roux reconstruction. Uncut Roux-en-Y gastrojejunostomy can be performed safely with improvement in symptoms. The uncut Roux procedure may provide an alternative for reconstructive gastric surgery.

Demography, clinical characteristics, psychological and abuse profiles, treatment, and long-term follow-up of patients with gastroparesis

Patients with gastroparesis frequently present challenging clinical, diagnostic, and therapeutic problems. Data from 146 gastroparesis patients seen over six years were analyzed. Patients were evaluated at the time of initial diagnosis and at the most recent follow-up in terms of gastric emptying and gastrointestinal symptomatology. The psychological status and physical and sexual abuse history in female idiopathic gastroparesis patients were ascertained and an association between those factors and gastrointestinal symptomatology was sought. Eighty-two percent of patients were females (mean age: 45 years old). The mean age for onset of gastroparesis was 33.7 years. The etiologies in 146 patients are: 36% idiopathic, 29% diabetic, 13% postgastric surgery, 7.5% Parkinson's disease, 4.8% collagen vascular disorders, 4.1% intestinal pseudoobstruction, and 6% miscellaneous causes. Subgroups were identified within the idiopathic group: 12 patients (23%) had a presentation consistent with a viral etiology, 48% had very prominent abdominal pain. Other subgroups were gastroesophageal reflux disease and nonulcer dyspepsia (19%), depression (23%), and onset of symptoms immediately after cholecystectomy (8%). Sixty-two percent of women with idiopathic gastroparesis reported a history of physical or sexual abuse, and physical abuse was significantly associated with abdominal pain, somatization, depression, and lifetime surgeries. At the end of the follow-up period, 74% required continuous prokinetic therapy, 22% were able to stop prokinetics, 5% had undergone gastrectomy, 6.2% went onto gastric electrical stimulation (pacing), and 7% had died. At some point 21% had required nutrition support with a feeding jejunostomy tube or periods of parenteral nutrition. A good response to pharmacological agents can be expected in the viral and dyspeptic subgroups of idiopathics, Parkinson's disease, and the majority of diabetics, whereas a poorer outcome to prokinetics can be expected in postgastrectomy patients, those with connective tissue disease, a subgroup of diabetics, and the subset of idiopathic gastroparesis dominated by abdominal pain and history of physical and sexual abuse. Appreciation of the different etiologies and psychological status of the patients may help predict response to prokinetic therapy.

Management of gastrointestinal motility disorders. A practical guide to drug selection and appropriate ancillary measures

The focus of management of gastrointestinal motility disorders should be to improve survival and quality of life. Some motor disorders are annoying, but are compatible with virtually normal activity and carry no significant life risk. Conversely, other motor disorders are highly incapacitating and may shorten life expectancy because of complications and nutritional impairment. Management is based first on establishing the correct diagnosis and prognosis; secondly, on adjusting therapy to the severity of illness; and thirdly, on preventing significant complications. Simple recommendations on appropriate changes in lifestyle and reassurance may suffice in mild cases. Pharmacological therapy and, exceptionally, surgical or nutritional measures may be required in other patients. Generally, pharmacological agents should be directed towards correcting specific pathophysiological abnormalities, but this is not always possible. Symptomatic relief may be achieved on an empirical basis. Long term treatment may often require the combination of different therapeutic approaches either sequentially or simultaneously.

Delayed gastric emptying after gastric surgery

BACKGROUND

The reported incidence of delayed gastric emptying (DGE) after gastric surgery is 5% to 25% and usually is based on operations for peptic ulcer disease. Ongoing improvements in perioperative care, nutritional support, and new prokinetic drugs may have had a beneficial effect on the frequency and course of postoperative DGE.

METHODS

We therefore studied our recent experience with DGE in 416 patients who had gastric surgery for ulcer disease (283), cancer (92), or trauma and other indications (41) between January 1985 and December 1993. DGE was defined as inability to eat a regular diet by postoperative day 10.

RESULTS

DGE occurred in 99 of 416 patients (24%). In 75 of these 99 patients, a postoperative contributing factor for DGE was identified. These factors were sepsis (32), anastomotic edema and leaks (23), obstruction (4), pancreatitis (3), multiple system organ failure (5), and miscellaneous conditions (8). In 24 patients there was no obvious cause for DGE; these patients recovered with nutritional support and time. Re-operation specifically for gastric stasis was not performed. Among the 99 patients with DGE, 67% were eating by day 21, 92% by 6 weeks, and 100% by 10 weeks. Significant risk factors for DGE were diabetes (55%), malnutrition (44%), and operations for malignancy (38%). The Whipple procedure had the highest incidence of DGE (70%), highly selective vagotomy the lowest (0%), while truncal vagotomy had no significant effect. The response to metoclopramide was 20% and unpredictable.

CONCLUSION

DGE continues to affect a considerable number of our patients (24%) after gastric surgery and is particularly common in patients with diabetes, malnutrition, and gastric or pancreatic cancer. However, gastric motility does return in 3 to 6 weeks in most patients and the need for re-operation for gastric stasis is rare.

Effects of highly selective vagotomy and additional procedures on gastric emptying in patients with obstructing duodenal ulcer

A solid gastric emptying study was conducted on 46 patients more than 1 year after highly selective vagotomy (HSV) and additional procedures for obstructing duodenal ulcer and on 21 patients after HSV alone for uncomplicated duodenal ulcer. The additional procedures included dilatation (n = 14; HSV + D group), Holle pyloroplasty (n = 14; HSV + P group), and Jaboulay gastroduodenostomy (n = 18; HSV + GD group). The test meal consisted of two eggs labeled with 99mTc sulfur colloid, two slices of white bread toast, and 300 ml of orange juice (total 322 kcal). Gastric emptying curves and emptying parameters (t1/2, half emptying time; lag phase, TLAG; emptying rate, k; and beta value) were compared with those of 17 healthy volunteers, the normal control group. The patients after HSV alone had an almost normal gastric emptying. The HSV + D group showed a significant delay from minute 45 to the end of the emptying curve, corresponding to a longer t1/2 (p = 0.02), and a slower emptying rate (p = 0.029). The HSV + P group approached a nearly normal emptying curve, corresponding to an insignificant difference in emptying parameters. The HSV + GD group had significantly faster emptying from minute 15 to the end of the emptying curve, corresponding to a faster t1/2 (p = 0.0005), a shorter lag phase (p = 0.027), and a faster emptying rate (p = 0.021). Recurrent ulcerations were noted in one patient (4.8%) of the HSV alone group, five (35.7%) of the HSV + D group, one (7.1%) of the HSV + P group, and one (5.6%) of the HSV + GD group.(ABSTRACT TRUNCATED AT 250 WORDS)