Best Treatment for Gastroparesis: Gastric Bypass or Gastric Sleeve?

Gastroparesis or delayed gastric emptying occurs when the stomach is paralyzed and gastric emptying is impaired. As a result, patients report bloating, nausea, vomiting, and pain. The underlying pathophysiology of gastroparesis is poorly understood. The cause of gastroparesis is also unknown. When patients with diabetes develop gastroparesis, the condition is called diabetic gastroparesis. It appears that in diabetic patients enteric nerve damage results in gastric dysmotility. However, the relationship between diabetes and gastroparesis is far more complex than a simple neuropathy. Normally, rising blood sugar levels halt gastric emptying as a protective measure against further nutrient passage into the intestines and sugar absorption. In type 2 diabetic patients abnormal gastric emptying may be the cause of diabetes rather than the result. In fact, type 2 Diabetes may be looked at as a gastro-intestinal motility disorder resulting in insulin resistance. Dr. Mason, the father of bariatric surgery, is an avid proponent of this theory. The early resolution of type 2 Diabetes immediately following gastric bypass and sleeve surgery is partly secondary to faster delivery of food to the distal small bowel. Gastric sleeve increases gastric emptying allowing food particles to reach the distal bowel to stimulate more L cells leading to increased GLP-1 secretion. L cells are specialized cells that react to glucose in ingested food and secrete several hormones like GLP-1 that affect glucose metabolism. GLP-1 stimulates insulin secretion and blocks glucagon secretion hence improving post-prandial blood sugar levels.

Several studies have shown that gastric sleeve surgery increases gastric emptying. Few years ago, I used this concept to treat a severe case of diabetic gastroparesis in a 45-year-old male. I performed a longitudinal gastrectomy to mimic the effects of gastric sleeve and improve gastric emptying. I also added a duodeno-jejunostomy to promote duodenal emptying. The patient immediately improved and was tolerating regular diet few days after surgery. Interestingly, his diabetes resolved immediately after surgery. This observation shows again that type 2 Diabetes is primarily a gastro-intestinal motility disorder. I did not consider a gastric bypass in this particular patient because the stomach was massively dilated. Gastric remnant secretion would accumulate in the stomach causing symptoms. A recent study from the Cleveland Clinic showed that gastric bypass surgery is effective in morbidly obese gastroparesis patients and safer than subtotal gastrectomy. The series was small (7 patients) and the follow up was short. Two patients were converted to subtotal gastrectomy for persistent gastroparesis related symptoms following gastric bypass surgery. In my opinion, gastroparesis is a generalized motility disorder that affects the duodenum and sometimes the entire small bowel. Simply bypassing the stomach and proximal bowel may not resolve the symptoms especially in severe cases. A modified gastric sleeve or longitudinal gastrectomy is a more effective option that addresses the underlying problem. By resecting the gastric fundus and most of the greater curvature, stomach compliance decreases leading to improved gastric emptying. Furthermore, the malfunctioning gastric pacemaker that is located along the greater curvature is eliminated and potentially leading to increased motility. I recommend leaving the antrum intact as it represents the gastric pump and may help promote gastric emptying.

In summary, gastrointestinal motility affects many functions in the body and contributes to many diseases like acid reflux, diabetes and obesity. Gastric motility patterns are highly coordinated and still poorly understood. Lessons learned in gastric sleeve surgery may be applied to severe refractory gastroparesis cases. Future studies are needed to establish longitudinal gastrectomy as an effective treatment modality for gastroparesis.

Obesity and GERD: Weight loss surgery options

GERD remains an intriguing disease with several important unanswered questions about its rising incidence, precipitating factors, underlying pathophysiology and relationship to the obesity epidemic. Today, around one-third of all Americans experience a GERD-related symptom at least once weekly.

Esophageal adenocarcinoma, a complication of GERD, is the fastest-rising cancer in the U.S. Abdominal girth and excess weight contribute to GERD. Several studies demonstrate a strong, almost linear association between BMI and GERD. Obesity may promote the development of GERD. If true, what would be the underlying mechanism?

The link between obesity and GERD seems to be related to increased intra-abdominal pressure secondary to abdominal fat accumulation. Intra-gastric pressure increases, promoting a backflow of gastric content into the esophagus. Several studies have shown that GERD patients’ increasing BMI is independently associated with increased intra-gastric pressure. While logical, these findings are a simplistic interpretation of a complex problem.

GERD is a result of a weak LES

GERD pathogenesis is centered on the gastroesophageal junction (GEJ). This complex and dynamic structure is comprised of the lower esophageal sphincter — the surrounding crural diaphragm — the angle of Hiss (angle where the intra-abdominal esophagus joins the stomach) — and the phrenoesophageal membrane (PEM). The diaphragmatic crura prevent strain-induced reflux events, while the angle of Hiss configuration prevents increased gastric pressure-induced reflux events. The PEM is composed of elastin intertwined with thick bundles of collagen. Elastin contributes to its elasticity and flexibility, while collagen confers strength. This delicate balance between flexibility and strength allows the remaining components of the GEJ to work in synchrony and with clocklike precision: relaxing, contracting and contorting to gastric pressure variations with upward esophageal movements to prevent reflux. Secondary to obesity, a persistent elevated intra-abdominal pressure may challenge the delicate PEM (the Achilles heel of the anti-reflux barrier). A weak and lax PEM causes anatomic changes in the structure of the GEJ that evolve into functional failure of multiple acid reflux defense mechanisms like low sphincter pressure, transient lower esophageal sphincter relaxation, prolonged acid clearance, and changes in the post-prandial acid pocket position. The end result is the development of an overt hiatal hernia: the only independent predictor for GERD.

Weight loss surgery options rather than acid suppression

Interestingly, increased gastric acid secretion is not a contributing factor in the GERD pathogenesis — quite a paradox in that acid suppression has been the mainstay of GERD therapy for the past 50 years. Particularly in the obese patient population, GERD treatment should mainly rely on weight loss rather than acid suppressive therapy. The most effective weight loss therapy for obese patients is bariatric surgery. Roux-en-Y gastric bypass surgery is an established anti-reflux procedure. It diverts the acid-producing stomach away from the esophagus. The literature remains ambivalent on the effect of sleeve gastrectomy in resolving acid reflux disease. Is gastric fundus resection during sleeve gastrectomy equivalent to gastric fundus plication during a Nissen fundoplication surgery? A recent prospective study by Morino et al. showed resolution of symptomatic GERD following sleeve gastrectomy in morbidly obese patients. Will the sleeve gastrectomy have a role in GERD treatment in obese patients?

Additional studies are needed to answer these questions. As GERD continues to rise, new screening, diagnostic and treatment paradigms will emerge.

The rise of Gastric Sleeve procedure for weight loss

comparison-of-surgical-weight-loss-methods

The rising Gastric Sleeve is replacing older and ineffective procedures like adjustable gastric banding. Gastric sleeve surgery is a metabolic procedure that alters several hormones that control appetite, satiety and energy metabolism. The end result is significant and durable weight loss. At Houston Weight Loss Surgery Center, we offer the gastric sleeve surgery as a first line weight loss surgery option for almost 80% of our patients. Gastric bypass surgery is reserved for revisions and advanced diabetes cases. We don’t offer adjustable gastric banding, however, we offer gastric band adjustments and management to patients who has already received a band. Our revision surgery mainly consist of band conversion to gastric bypass. Continue reading “The rise of Gastric Sleeve procedure for weight loss”

Lap Band Revision Surgery Houston

Is Sleeve surgery a good option for patients with heartburn?

The incidence of heartburn in our overweight patient population is very high. Heartburn results when acid backs up into the esophagus. Normally, a competent lower esophageal sphincter, LES, acts as a barrier against acid reflux into the esophagus. With weight gain, fat accumulates inside the abdomen increasing the pressure on the stomach and leading to acid reflux. Furthermore, a higher intra-abdominal pressure increases the incidence of a hiatal hernia. A hiatal hernia occurs when part of the stomach herniates into the chest thereby leading to a weak LES. To make things worse, overweight individuals tend to overeat especially at dinnertime. Overeating stretches and weakens the LES, further aggravating the reflux of acid. Delayed gastric emptying and a dilated gastric fundus (upper part of the stomach) promote the development of a permanent “acid bubble” in close proximity to the LES which in turn may contribute to the increased incidence of acid reflux in this patient population.

At Houston Weight Loss Surgery Center, we offer the sleeve gastrectomy for most patients with a body mass index (BMI) higher than 35 and suffering from heartburn. Sleeve surgery allows for long-term effective weight loss leading to alleviation of most acid reflux symptoms. Sleeve gastrectomy is currently the most commonly performed weight loss procedure around the world. During sleeve surgery 85% of the stomach is resected ending up with a banana shaped stomach. As you loose weight following sleeve surgery, heartburn tends to resolve. A recent study published in the Annals of Surgery by Dr. Morino showed that heartburn resolves after sleeve gastrectomy in the majority of patients who suffered from gastro-esophageal reflux disease (GERD) prior to surgery. The study also showed that new onset acid reflux after sleeve gastrectomy is rare. Interestingly, the study demonstrated that sleeve surgery increases the pressure of the lower esophageal sphincter, LES, hence strengthening the acid reflux barrier. This is an additional anti-reflux property for the sleeve that is independent of weight loss.

At Houston Weight Loss Surgery Center, the only contraindication for sleeve surgery in GERD (gastro-esophageal reflux disease) patients is the presence of Barrett’s esophagus. Barrett’s esophagus results from long standing severe acid reflux and possible bile reflux into the lower esophagus. In this case, gastric bypass surgery is a better option for weight loss. Gastric bypass diverts acid and bile from the lower esophagus therefore preventing and halting the progression of Barrett’s into cancer. Gastric bypass also preserves the rest of the stomach in case it is needed in the future for reconstructive surgery if esophageal surgery is ever needed.

If you have persistent heartburn and interested in weight loss, Dr. Darido offers state of the art effective solutions for both heartburn and excess weight. Please give us a call at 281.205.3205 for a free private consultation at Houston weight loss surgery center.

What is Gastric Plication?

Gastric plication also known as greater curvature plication is a new procedure for weight loss that was introduced few years ago to the United States. The procedure involves reducing the gastric size by folding the stomach wall inside its lumen. Stitches are then placed to hold the folded stomach in place. The surgery mechanism of action for gastric plication is restriction, i.e. forcing the patient to eat less by reducing stomach size. This assumption has never led to any durable weight loss throughout the history of bariatric surgery.

Unlike sleeve gastrectomy or gastric bypass there is no stapling or cutting. The procedure was introduced to the public as safe, less invasive and as effective as a sleeve gastrectomy. Some surgeons went on to add an adjustable gastric band to gastric plication, assuming that the more restriction the better. Within 2 to 3 years, the initial enthusiasm about this novel procedure quickly faded. Weight loss, as expected, was not that great. Patients had excessive nausea and vomiting after surgery. The folded stomach herniated through the suture line causing leaks in certain cases. Hunger feeling was not controlled most likely because gastric plication did not decrease hunger hormones like Ghrelin. As a result weight loss was not sustainable and gastric plication failed to prove itself as a safe, durable and effective weight loss procedure.

Understanding weight loss surgery mechanism of action is crucial for the development of new effective weight loss procedures. Obesity is a complex multifactorial disease that results in functional deficiency of many neuro-hormonal signals that would normally arise after a meal. Restoring these signals, rather than restriction, should be the guiding principle for developing new weight loss procedures.