End of the road for a dysfunctional end organ: laparoscopic gastrectomy for refractory gastroparesis

Gastroparesis: An Evidence-Based Review for the Bariatric and Foregut Surgeon

Gastroparesis is a gastric motility disorder characterized by delayed gastric emptying. It is a rare disease and difficult to treat effectively; management is a dilemma for gastroenterologists and surgeons alike. We conducted a systematic review of the literature to evaluate current diagnostic tools as well as treatment options. We describe key elements in the pathophysiology of the disease, in addition to current evidence on treatment alternatives, including nutritional considerations, medical and surgical options, and related outcomes.

Systematic review on sleeve gastrectomy or Roux-en-Y gastric bypass surgery for refractory gastroparesis

Management of refractory gastroparesis is challenging after diet, prokinetics, and long-term nutritional support have failed. In this review, the efficacy and safety of surgical interventions (sleeve gastrectomy and Roux-en-Y gastric bypass surgery) are evaluated systematically in patients with refractory gastroparesis. The PubMed, Embase, and Scopus databases were searched to identify relevant studies published up to June 2021. Outcome of interest was symptom improvement and gastric emptying. Nineteen studies with 222 refractory gastroparesis patients (147 Roux-en-Y gastric bypass, 39 sleeve gastrectomy, and 36 subtotal gastrectomy) were included. All studies reported symptom improvement postoperatively, particularly vomiting and nausea. Gastric emptying improved postoperatively in 45% up to 67% for sleeve gastrectomy and 87% for Roux-en-Y gastric bypass. The findings of our systematic review suggest that sleeve gastrectomy and Roux-en-Y gastric bypass surgery improve symptoms and gastric emptying in patients with refractory gastroparesis. Surgery may be effective as treatment for a small group of patients when all other therapies have failed.

Gastric electric stimulator versus gastrectomy for the treatment of medically refractory gastroparesis

BACKGROUND

Gastric electrical stimulation (GES) and laparoscopic gastrectomy (LG) are known therapeutic options for medically refractory gastroparesis (MRG) although there are limited data comparing their outcomes. We aim to compare clinical outcomes between patients undergoing GES vs upfront LG for the treatment of MRG while examining factors associated with GES failure and conversion to LG.

METHODS

We retrospectively analyzed 181 consecutive patients who underwent GES or LG for MRG at our institution from January 2003 to December 2017. Data collection consisted of chart review and follow-up telephone survey. Statistical analysis utilized Chi-squared, ANOVA, and multivariable logistic regression.

RESULTS

Overall, 130 (72%) patients underwent GES and 51 (28%) LG as primary intervention. GES patients were more likely to have diabetic gastroparesis (GES 67% vs LG 39%, p < 0.001), while primary LG patients were more likely to have post-surgical gastroparesis (GES 5% vs LG 43%, p < 0.001). Postoperatively, primary LG patients had higher rates of major in-hospital morbidity events (GES 5% vs LG 18%, p = 0.017) and longer hospital stays (GES 3 vs LG 9 days, p < 0.001). However, over a mean 35-month follow-up period, there were no differences in the rates of major morbidity, readmissions, or mortality. Multivariable regression analysis revealed patients undergoing GES as a primary intervention were less likely to report improvement in symptoms on follow-up compared to primary LG patients OR 0.160 (95% CI 0.048-0.532). Additionally, patients who converted to LG from GES were more likely to have post-surgical gastroparesis as the primary etiology.

CONCLUSION

GES as a first-line surgical treatment of MRG was associated with worse outcomes compared to LG. Post-surgical etiology was associated with an increased likelihood of GES failure, and in such patients, upfront gastrectomy may be a superior alternative to GES. Further studies are needed to determine patient selection for operative treatment of MRG.

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.

Gastric per-Oral Endoscopic Myotomy for Refractory Gastroparesis: A Meta-Analysis

BACKGROUND

The emerging gastric per-oral endoscopic myotomy (G-POEM) is becoming an alternative treatment method for gastroparesis. This study aimed to evaluate the feasibility and safety of G-POEM for gastroparesis.

METHODS

Relevant publications were identified through searching PubMed, EMBASE, Cochrane Library, and Web of Science before April 1, 2019. Studies presenting the clinical data of G-POEM for the treatment of gastroparesis were included. Data about effectiveness and safety were extracted, pooled, and analyzed. Forest plots were graphed based on random effects models.

RESULTS

A total of 272 patients representing 8 studies were eligible for analysis. The pooled rates of GCSI at preprocedure, 1-3 months, 6 months, and 12 months, were 3.25 (95% CI, 2.75-3.75), 1.80 (95% CI, 1.10-2.49), 1.56 (95% CI, 0.45-2.68), and 1.10 (95% CI, 0.75-1.45), respectively. The pooled results of 4-h GES pre- and post-G-POEM were 41.89% (95% CI, 32.75-51.03%) and 16.48% (95% CI, 9.83-23.14%), respectively. Furthermore, the pooled clinical response rate was 84% (95% CI, 77-89%). The GES improvement rate and GES normal rate were also analyzed, and the results were 84% (95% CI, 77-90%) and 53% (95% CI, 39-66%), respectively. Finally, the pooled adverse events rate was 12% (95% CI, 6-19%).

CONCLUSIONS

G-POEM was shown to be feasible and safe for the treatment of gastroparesis with various etiologies, which could be a potential first-line therapy for certain patients. Future studies are needed to investigate the appropriate patients for G-POEM to explore the "most beneficial" subgroup of patients.

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.

Endoscopic and Surgical Treatments for Gastroparesis: What to Do and Whom to Treat?

Gastroparesis is a complex chronic debilitating condition of gastric motility resulting in the delayed gastric emptying and multiple severe symptoms, which may lead to malnutrition and dehydration. Initial management of patients with gastroparesis focuses on the diet, lifestyle modification and medical therapy. Various endoscopic and surgical interventions are reserved for refractory cases of gastroparesis, not responding to conservative therapy. Pyloric interventions, enteral access tubes, gastric electrical stimulator and gastrectomy have been described in the care of patients with gastroparesis. In this article, the authors review current management, indications, and contraindications to these procedures.

Pathophysiology, Aetiology and Treatment of Gastroparesis

Gastroparesis is characterized by delayed gastric emptying, with symptoms such as nausea, vomiting and abdominal pain, in the absence of mechanical obstruction. In most cases, it is idiopathic although diabetes mellitus is another leading cause. The physiology of gastric emptying is a complex process which is influenced by various inputs including the central nervous system, enteric nervous system and gut hormones. Developments in our understanding of gastroparesis have now demonstrated dysfunction in these systems, thus disrupting normal gastric emptying. Once mechanical obstruction is excluded, gastric scintigraphy remains the gold standard for diagnosis although wireless motility capsule and breath testing are alternative methods for diagnosis. Treatment for gastroparesis is challenging, and widely available therapies are often limited either by their poor evidence for efficacy or concerns over their long-term safety profile. Novel prokinetic agents have shown initial promise in clinical trials, and new endoscopic techniques such as gastric per-oral endoscopic myotomy are emerging. These new treatment modalities may provide an option in refractory gastroparesis with the adage of reduced morbidity compared to surgical treatments.

Patient factors influence surgical options in gastroparesis

BACKGROUND

Patient selection for the diverse surgical procedures for gastroparesis remains poorly defined. Our aim was to evaluate how patient factors have determined our surgical approach to gastroparesis.

METHODS

95 patients undergoing 105 surgical procedures for gastroparesis were reviewed. Patient factors were compared across six surgical procedures: gastric neurostimulator, pyloroplasty, neurostimulator plus pyloroplasty, sleeve gastrectomy, gastric bypass and gastrectomy. Global symptom severity was determined preoperatively and at last follow up.

RESULTS

There were significant differences in etiology, BMI and gastroesophageal reflux across the various operations. Patients undergoing pyloroplasty and gastrectomy; were more likely to have a postsurgical etiology. (p < .05) Patients undergoing sleeve gastrectomy and gastric bypass were more likely to have BMI >35. ^{(p <.05)} Those undergoing sleeve gastrectomy were less likely to have gastroesophageal reflux preoperatively. ^{(p <.05)} There was no difference in preoperative clinical stage across the procedures.

CONCLUSION

Patient factors influence choice of procedure in the surgical treatment of gastroparesis. Etiology of gastroparesis, BMI >35 and gastroesophageal reflux are important determinants.

Minimally Invasive Surgical Approach for the Treatment of Superior Mesenteric Artery Syndrome: Long-Term Outcomes

BACKGROUND

Latero-lateral duodenojejunostomy is the treatment of choice for superior mesenteric artery syndrome (SMAS). The present study analyzes the long-term outcomes in 13 patients undergoing laparoscopic surgery for SMAS.

MATERIALS AND METHODS

A retrospective study of 10 females and three males undergoing surgery between 2001 and 2013 was performed. Demographic, clinical and radiologic data and long-term surgical outcomes were recorded. In 12 patients latero-lateral duodenojejunostomy and in one patient distal laparoscopic gastrectomy with Roux-en-Y reconstruction were performed. The median age was 24 years (20-28), and the median duration of symptoms was 24 months (5-24). The most frequent symptoms were abdominal pain (n = 11; 92.3%), nausea and vomiting (n = 10; 77%) and weight loss (n = 9; 69.2%). The median operating time was 98 min (86-138) and hospital stay was 3 days (1-14).

RESULTS

No reconversions occurred, and one patient experienced gastric emptying delay in the immediate postoperative period with spontaneous resolution. In four patients, SMAS was associated with severe stenosis of the celiac trunk which was treated in the same operation, and four patients presented stenosis of the left renal vein (the "nutcracker" phenomenon). With a median follow-up of 94 months (SD 65.3), eight patients (61.5%) had excellent results. One patient had a relapse of symptoms 4 years after surgery requiring distal gastrectomy, two patients presented delay in gastric emptying following temporary improvement and one patient experienced no improvement.

CONCLUSIONS

Latero-lateral duodenojejunostomy yields good results in SMAS although it requires other gastric motility disorders to be ruled out for appropriate treatment to be established.

Sleeve gastrectomy for treatment of delayed gastric emptying-indications, technique, and results

INTRODUCTION

Delayed gastric emptying (DGE) can be caused by gastric motility disorders such as gastroparesis with idiopathic background, diabetic neuropathy, or postsurgical nerve damage. Currently, a variety of endoscopic and surgical treatment options are available. We noted clinical improvement of gastric emptying with reduction of the gastric fundus following both fundoplication and fundectomy. As a consequence, we explored the effect of sleeve gastrectomy on gastric emptying. The focus of this paper is to investigate the role of laparoscopic sleeve gastrectomy (LSG) in the treatment of gastroparesis.

METHODS

Patients with symptoms suggestive of gastroparesis received diagnostic work-up (gastric emptying scintigraphy and/or Radiographic Barium-Sandwich Emptying studies). Patients with fundic emptying problems and moderate gastric dilation were selected for a LSG. All perioperative parameters were documented regarding patients characteristics, complications, and outcomes expressed as symptoms and quality of life (GIQLI gastrointestinal quality of life index). Assessment of DGE: Barium Emptying Radigraphy Index (BERI) 0-5.

RESULTS

From 122 patients with gastroparesis, 19 patients were selected for LSG (mean age 54 years (23-68); 10 males/9 females. Morbidity 2/19; no mortality; follow-up mean 24 months (12-60); preop/postop: BERI: 2, 31/1, 27 (p < 0.01); we noted significant improvement of the quality of life (preoperative GIQLI 78 (44-89)) to postoperative values of 114 (range 87-120) (p < 0.0001). Preoperative median BMI of these 19 patients was 24 [1-10], which was not significantly changed in the 15 patients at > 1 year follow-up with 23 [1-8]. Postoperative recurrence of DGE occurred in 3 patients who were reoperated after >1 year follow-up.

CONCLUSION

LSG is a potential surgical treatment option for selected patients with gastroparesis and fundic emptying problems.

Per-oral Pyloromyotomy (POP) for Medically Refractory Gastroparesis: Short Term Results From the First 100 Patients at a High Volume Center

OBJECTIVE

For patients with gastroparesis, temporary pyloric disruption has been shown to improve symptoms and gastric emptying. Per-oral pyloromyotomy (POP) is an innovative endoscopic procedure to divide the pylorus from within a submucosal tunnel, as a corollary to surgical pyloromyotomy. Here we evaluate subjective and objective outcomes 12-weeks after POP at a high volume center.

METHODS

The first 100 consecutive patients undergoing POP were included, with procedure dates between January 2016 and October 2017. Patients were evaluated using the Gastroparesis Cardinal Symptom Index (GCSI), and 4-hour solid-phase scintigraphic gastric emptying studies (GES) prior to procedure and at 90 days post-POP RESULTS:: The study cohort was 85% female with a mean age of 45.0 ± 14.6 years. Gastroparesis etiologies were divided among idiopathic (56%), diabetic (21%), postsurgical (19%), and other in 4%. There were 67% of the patients who had previous endoscopic or surgical interventions for gastroparesis. Most POP procedures were performed in the operating room (97%) and were completed in an average of 33 minutes. Ten patients incurred complications (10%), which included 1 diagnostic laparoscopy and 2 cases of gastrointestinal bleeding. Overall GCSI improved from a preoperative mean of 3.82 ± 0.86 to 2.54 ± 1.2 (P < 0.001). The improvement in each GCSI subscore was also highly statistically significant. Among the patients with postoperative GES available, 78% had objectively better 4-hour emptying with a mean improvement in retention by 23.6% (P < 0.001). This included 57% of patients with normal gastric emptying post-POP.

CONCLUSION

For patients with medically refractory gastroparesis, POP results in both subjective and objective improvement in the majority of patients. Prior intervention does not obviate POP as a therapeutic option. POP should be included along the treatment algorithm for patients with gastroparesis as an organ-sparing procedure.

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.

Surgical Management for Gastroparesis

Gastroparesis is a debilitating chronic condition of indeterminate cause. Although conservative management is the mainstay of treatment, a significant percentage of patients will need interventions. Interventions range from supportive measures, such as feeding tubes, to more radical surgeries, including endoscopic pyloromyotomy (per oral pyloromyotomy), laparoscopic pyloroplasty, laparoscopic gastric stimulator placement, and even subtotal or total gastrectomy. The authors present some current treatment algorithms focused on the treatment side of the spectrum along with outcomes data to support the various approaches.

The Investigation and Treatment of Diabetic Gastroparesis

PURPOSE

This review provides an update on the investigations and treatment options for gastroparesis.

METHODS

A comprehensive literature search of Medline, PubMed, Embase and OVID was conducted which included all systematic reviews and research articles that focused on the diagnosis, investigations and management diabetic gastroparesis.

FINDINGS

Dietary modifications and pharmacologic treatment with prokinetics to increase gastric motility form the mainstay of treatment. However, the use of prokinetics is limited by adverse effects and serious adverse effects, leaving metoclopramide as the only drug approved by the US Food and Drug Administration for the treatment of gastroparesis. Newer therapies, including motilin receptor agonists, ghrelin receptor agonists, and neurokinin receptor antagonists, are currently being investigated. Transpyloric stenting, gastric electrical stimulation, and gastric per-oral endoscopic myotomy provide mechanical options for intervention, and surgical interventions in severe intractable gastroparesis include laparoscopic pyloroplasty or gastrectomy.

IMPLICATIONS

Advances to better understand the pathophysiology and management of diabetic gastroparesis have been limited, especially with discordance between symptoms and severity of delay in gastric emptying. Established treatment options are limited; however, recent pharmacologic and surgical interventions show promise.

Endoscopic Therapies for Gastroparesis

PURPOSE OF REVIEW

Gastroparesis remains a difficult-to-treat disease with limited therapeutic options. Though patients often have a common syndrome of stereotypic symptoms, the underlying pathophysiology is heterogeneous, often leading to variable treatment responses. Due to limitations in medical and surgical therapies, endoscopic options have been increasingly explored. These options can be broadly categorized into pyloric-directed therapy, non-pyloric-directed therapy, and nutritional support. In this review, we will highlight current and emerging endoscopic options, such as gastric per-oral endoscopic myotomy (G-POEM).

RECENT FINDINGS

Early retrospective studies on G-POEM offer encouraging results up to one year out, with an acceptable safety profile. Other pyloric-directed therapies, such as pyloric dilation and stenting, have also been explored. While emerging endoscopic therapeutic options are encouraging, efficacy will likely depend on a better characterization of underlying pathophysiology and improved patient selection. Future prospective, controlled studies are needed.

Early Assessment of Cost-effectiveness of Gastric Electrical Stimulation for Diabetic Nausea and Vomiting

Background/Aims

Recurrent nausea and/or vomiting are common complications of diabetes mellitus. The conditions severely impact the quality of life of patients and often cause repeated admissions to hospital incurring significant healthcare costs. If standard treatment fails, gastric electrical stimulation (GES) may be offered in selected cases, as a minimally invasive, but expensive, therapeutic option. Our aims are to evaluate the clinical effect and the cost-utility of GES as a treatment for severe diabetic recurrent nausea and/or vomiting.

Methods

Among 33 diabetes patients implanted with GES because of recurrent nausea and/or vomiting, 30 were available for evaluation. The effect of treatment was assessed prospectively using symptom-diaries and the SF-36 questionnaires at baseline, after 6 and 12 months, and thereafter yearly. The number of days in hospital due to symptoms related to gastrointestinal dysfunction was calculated using hospital records 12 months prior to and 12 months after implantation.

Results

The surgical procedures were performed without mortality or major complications. Six months after surgery 78% of the respondents had at least 50% reduction in time with nausea and 48% had at least 50% reduction in days with vomiting. Symptom relief persisted at follow-up after at least 4 years. Quality adjusted life years improved after GES, which was cost-effective after 24 months.

Conclusions

GES reduces symptoms and improves quality of life in diabetes patients with recurrent nausea and/or vomiting. The procedure is supposed as cost-effective over a 2-year time horizon.

Diabetes and the Stomach

OPINION STATEMENT

Longstanding diabetes mellitus (both type 1 and type 2) can impair gastric motor function and cause significant upper gastrointestinal symptoms which significantly degrade quality of life, cause nutritional deficits, and degrade healthcare resource use. The most commonly considered gut complication of diabetes, diabetic gastroparesis, is a syndrome of delayed gastric emptying in the absence of mechanical obstruction which leads to symptoms of nausea, vomiting, postprandial fullness, early satiation, bloating, and upper abdominal pain. Gastroparesis also can lead to loss of glycemic control. A diagnosis of gastroparesis is made by documenting delayed gastric emptying and excluding mechanical obstruction. Gastric emptying scintigraphy is the most commonly utilized test for the diagnosis of gastroparesis but novel tests of gastric function have recently been introduced including the gastric emptying breath test and wireless motility capsule. Management most often is aimed at controlling symptoms, which includes dietary modification, optimization of glycemic control, and medication therapy with prokinetics, antiemetics, and neuromodulatory agents. Endoscopic and/or surgical therapies may be considered for refractory cases of gastroparesis. Recent research has provided new insights into the pathophysiology of this disease and is characterizing potential benefits of novel therapeutic agents which show promise in the treatment of this condition. This article will review the pathophysiology, new insights into disease mechanism, and treatment options for diabetic gastroparesis.

Gastroparesis: Medical and Therapeutic Advances

Gastroparesis is a chronic, bothersome, and often disabling neuromuscular disorder of the upper gastrointestinal tract. The most frequently reported symptoms of gastroparesis include nausea, vomiting, epigastric pain, early satiety, and unintentional weight loss. Etiologies of gastroparesis include diabetes, connective tissue disorders, prior infection, mesenteric ischemia, and post-surgical complications. The largest category of gastroparesis patients is comprised of those in whom no definitive cause can be identified (idiopathic gastroparesis). The individual and societal burden of gastroparesis is substantial. It considerably reduces patients' quality of life accompanied by a significant negative impact to the healthcare system. The current treatments of gastroparesis are less than ideal. Dietary modification may improve symptoms in patients with mild disease. Metoclopramide is the only medication currently approved for the treatment of gastroparesis; however, it is associated with adverse effects in a sizable proportion of patients. Other medications are frequently employed to treat symptoms of nausea and vomiting, although technically all are used off-label since they are not FDA approved for the treatment of gastroparesis. These data highlight the need to identify novel, more effective treatment options for this disabling disease. This review will provide a brief synopsis on the epidemiology, etiology, and impact of gastroparesis, discussing new therapeutic advances.

A quantified risk-scoring system and rating model for postsurgical gastroparesis syndrome in gastric cancer patients

BACKGROUND AND OBJECTIVES

The study aimed to investigate the relationship between obesity and postsurgical gastroparesis syndrome (PGS), and to construct a scoring system and a risk model to identify patients at high risk.

METHODS

A total of 634 patients were retrospectively analyzed. Clinical characteristics were evaluated via receiver operating characteristic (ROC) curve analysis. Logistic analysis was performed to determine the independent predictive indicators of PGS. A scoring system consisting of these indicators and a risk-rating model were constructed and evaluated via ROC curve analysis.

RESULTS

Based on the ROC curves, the visceral fat area (VFA) cutoff value for PGS was 94.00. Logistic analysis showed that visceral obesity (VFA ≥ 94.00 cm² ), the reconstruction technique, and tumor size were independent prognostic factors for PGS. The scoring system could predict PGS reliably with a high area under the ROC curve ([AUC] = 0.769). A high-risk rating had a high AUC (AUC I = 0.56, AUC II = 0.65, and AUC III = 0.77), indicating that the risk-rating model could effectively screen patients at high risk of PGS.

CONCLUSIONS

Visceral obesity defined by VFA effectively predicted PGS. Our scoring system may be a reliable instrument for identifying patients most at risk of PGS.

[Gastroparesis - causes, diagnosis and treatment]

BACKGROUND Gastroparesis is a motility disorder of the stomach. The symptoms are non-specific: nausea and vomiting are most common. Stomach pains, early satiety, postprandial fullness and bloating are also frequent symptoms. Current diagnostic criteria require delayed gastric emptying in the absence of any detectable mechanical obstruction. In this review article we elucidate the causes, assessment and treatment options.MATERIAL AND METHOD Structured article search in Embase and PubMed.RESULTS A number of conditions can lead to gastroparesis. The most frequent somatic cause is diabetes mellitus. Gastroparesis may also be iatrogenically inflicted by means of surgery or drugs. It may be difficult to discriminate between functional dyspepsia and idiopathic gastroparesis. Examination is based on patient history, gastroscopy and measurement of the rate of gastric emptying. Biochemical tests are also relevant for differential diagnosis. The treatment is primarily symptomatic, and consists of dietary measures, fluid therapy, drugs, gastric electrical stimulation, or endoscopic or surgical intervention in the form of insertion of a feeding tube for nutrition and abdominal relief, pyloroplasty or gastrectomy.INTERPRETATION Gastroparesis is a serious motility disorder. The condition may have significant consequences for patients, entailing reduced quality of life, reduced workforce participation and a considerable need for health assistance.

Total gastrectomy for rare refractory gastroparesis in patient with syringomyelia: A good impact on quality of life

Syringomyelia is a chronic progressive disease of the spinal cord. In symptomatic patients, bilateral sensory motor signs and symptoms prevail, moreover they can develop gastrointestinal disorders, although few studies have succeeded in explaining this correlation so far.

We report a case of a 67-year-old woman with a history of pain in the back-lumbar spine and lower limbs, paresthesia and urinary incontinence. MRI revealed syringomyelia, extended from T3 to the medullary cone. Neurological picture was worsened by progressive and increasingly debilitating gastrointestinal symptoms refractory to dietary changes and medical treatment. Blood tests, gastrointestinal investigations and imaging were all normal apart from scintigraphy which confirmed delayed gastric emptying. The neurological symptoms disappeared after removal of an hemangioblastoma of the medullary cone. The persistent gastroparesis was treated by total gastrectomy with complete resolution of the patient's gastrointestinal symptoms.

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Syringomyelia is a spinal disorder rarely associated with gastrointestinal dysfunction.

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We present a case of refractory gastroparesis in a female patient with syringomyelia.

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Surgery may be indicated if dietary changes and medical management fails.

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We performed a total gastrectomy with improvement in the patient's quality of life.

Gastroparesis

PURPOSE OF REVIEW

This review summarizes recent progress in the epidemiology, pathophysiology, and treatment of gastroparesis.

RECENT FINDINGS

The relationship between delayed gastric emptying and symptom pattern in gastroparesis and, related to it, its separation from functional dyspepsia remains an area of controversy and uncertainty. Pathophysiological studies have focused on the role of pyloric resistance and duodenal motility in generation of symptoms. In diabetic patients, glycemic control did not determine short-term changes in gastric emptying rate in type 2 diabetes, but poor glycemic control was a major risk factor for long-term development of gastroparesis in type 1 diabetes. At the cellular level, diabetic gastroparesis is characterized by loss of interstitial cells of Cajal (ICCs), and this is inversely correlated to the number of CD206+ macrophages, which are thought to have a protective effect on ICCs. Treatment trials have focused on dietary factors and a nasal spray formulation of metoclopramide. A meta-analysis of prokinetic studies found no association between symptom improvement and enhancement of gastric emptying in gastroparesis. Two controlled studies showed no benefit of tricyclic antidepressants (nortriptyline, amitriptyline) in idiopathic gastroparesis and functional dyspepsia with delayed emptying.

SUMMARY

The relationship between delay in gastric emptying, symptom pattern, and response to prokinetic therapy in gastroparesis is poor. In diabetes, gastroparesis is characterized by loss of ICCs, and this is inversely correlated to the number of CD206+ macrophages. Dietary interventions may help to alleviate symptoms. Tricyclic antidepressants do not provide symptomatic benefit to patients with idiopathic gastroparesis.

Endoscopic approaches to gastroparesis

PURPOSE OF REVIEW

This review covers the cause, evaluation and treatment options for gastroparesis. Symptoms of delayed gastric emptying are increasingly seen by gastroenterologists and gastrointestinal surgeons. Endoscopy - both laparoscopic and flexible - is increasingly important in treatment algorithms for this problem.

RECENT FINDINGS

Gastroparesis is increasingly being seen in clinical practice. A progressive algorithm needs to be followed in these challenging cases: starting with medical treatment and diet modification, progressing through endoscopic treatments including new ones such as per-oral pyloromyotomy, and finally laparoscopic treatments including gastrectomy.

SUMMARY

Endoscopic interventions are effective treatments for certain gastroparesis patients. New procedures offer a minimally invasive alternative to more radical options and should probably be more widely adopted.

Laparoscopic pyloroplasty is a safe and effective first-line surgical therapy for refractory gastroparesis

INTRODUCTION

Surgical options for symptomatic delayed gastric emptying include gastric stimulator implantation, subtotal gastrectomy, and pyloroplasty. Pyloroplasty has been shown to improve gastric emptying yet is seldom described as a primary treatment for gastroparesis. We present a single-institution experience of laparoscopic Heineke-Mikulicz pyloroplasty (LP) as treatment for gastroparesis.

METHODS AND PROCEDURES

A prospective foregut surgery database was queried for LP over a 5-year period. Charts were reviewed for indications, complications, symptom score, and outcomes. Gastroparesis was defined by (1) abnormal gastric emptying study, (2) endoscopic visualization of retained food after prolonged NPO status, or (3) clinical symptoms suspicious of vagal nerve injury following complex re-operative foregut surgery. Results were analyzed using a paired T test and single-factor ANOVA.

RESULTS

One hundred and seventy-seven LP patients were identified and reviewed. One hundred and five had a concurrent fundoplication for objective reflux. There were no intraoperative complications or conversions to laparotomy. Overall morbidity rate was 6.8% with four return to OR and two confirmed leaks (1.1% leak rate). Average length of stay was 3.5 days, and readmission rate was 7%. Eighty-six percent had improvement in GES with normalization in 77%. Gastric emptying half-time decreased from 175 ± 94 to 91 ± 45 min. Nineteen patients (10.7%) had subsequent surgical interventions: gastric stimulator implantation (12), feeding jejunostomy and/or gastrostomy tube (6), or subtotal gastrectomy (4). Symptom severity scores for nausea, vomiting, bloating, abdominal pain, and early satiety decreased significantly at 3 months.

CONCLUSION

Laparoscopic pyloroplasty improves or normalizes gastric emptying in nearly 90% of gastroparesis patients with very low morbidity. It significantly improves symptoms of nausea, vomiting, bloating, and abdominal pain. Some patients may go on to another surgical treatment for GP, but it remains a safe and less invasive alternative to a subtotal gastrectomy in these clinically challenging patients.