Shabir asked: “I like to know right at this moment how long will it be when everyone who suffers from diabetic gastroparesis will get a g poem procedure when that seems to be the best solution and another thing I like to ask is why is there so little treatment options for diabetic gastroparesis in this day and age when there are so many people suffering. Thank you looking forward to hearing from”. Continue reading “Question of the Week: G-POEM for Gastroparesis” →

Bill asked us this interesting question this week: Can you please provide me with more information about gastric resection for treatment of gastroparesis?

I have severe refractory gastroparesis. My GI doctor and surgeon want me to do a pyloroplasty despite no evidence of vagal nerve damage. My issue is slowed motility. I already have a G and J tube. I’m very interested in your work with gastric fundus resection. I would like to learn more. I have an aunt who lives in Houston. Thank you. Continue reading “Is Pyloroplasty a Reasonable Solution for Gastroparesis?” →

A colleague presented this case on the SAGES Foregut Surgery Masters Program Collaboration:
70 year-old-male with history of esophageal perforation from a Boerhaave rupture, who had repair and omental patch about 4 years ago. Had progressive nausea, vomiting and epigastric pain after that, ultimately diagnosed with gastroparesis, likely vagal nerve injury. Also later diagnosed with SMA syndrome, which I suspected was from weight loss secondary to gastroparesis. Continue reading “How Do I Manage Advanced Gastroduodenoparesis?” →

“56-year-old female, with type II achalasia, underwent a POEM procedure in 2015 by our experienced advanced GI guy. Then, developed terrible reflux post POEM (positive pH study while on PPIs, DeMeester score of 45). Then, underwent a lap hiatal hernia repair and Toupet fundoplication by another surgeon, and her reflux symptoms improved slightly for a while, then worsened again (another positive pH study on PPI’s). On top of it all, now she’s developed gastroparesis (95% retention at 4 hours). So, next, she’s undergoing a G-POEM procedure, with very minimal improvement of her symptoms. Oh yeah, she also happens to test + for CYP2C19 mutation and is a rapid metabolizer of PPIs. So, she’s upped to Protonix 80mg TID by now, with poor symptomatic control and has objective evidence of LA Grade C esophagitis. As far as gastrinoma workup: Gastrin level of 700 on a PPI and negative secretin stimulation test.

What are the options now? Redo wrap? Anyone would convert her to a Roux-en-Y and if yes, how to minimize her (almost guaranteed) marginal ulcer formation? Mini-gastric pouch, vagotomy, etc? Her BMI is 17 and her main (worst) symptom is heartburn”.

This case was posted by a colleague on the SAGES Foregut Surgery Masters Program Collaboration Facebook page. It attracted my attention for several reasons. First, it illustrates the occurrence of acid reflux disease following POEM treatment of achalasia. Second, it demonstrates the futility of pyloroplasty for treatment of gastroparesis. Third, it shows that gastroparesis and its effect on GERD remain a poorly understood disease by most foregut surgeons. There are no treatment guidelines for gastroparesis and gastric bypass is often advocated as a treatment option for gastroparesis. There is however, no evidence that gastric bypass is a good solution for gastroparesis.

I have performed a longitudinal gastrectomy or modified sleeve gastrectomy on several gastroparesis patients with excellent results. Even in the setting of a fundoplication, a longitudinal gastrectomy below the wrap level that preserves the gastric antrum promotes gastric motility and cure gastroparesis. Accordingly, I strongly advocate this approach to the patient presented without the need to undo or redo the wrap or complicate the situation by adding a gastric bypass to an already malnourished patient.

Nathali from South Florida sent us this question this week:

Question

I was diagnosed one year ago with moderate Gastroparesis at Cleveland Clinic Weston, after I have been suffering with gastroenterology issues for over 10 years. I’ve seen many different GI’s. I had my gallbladder removed in 2015 (since my pain was always located in that area, my HIDA scan was borderline). In 2016, I had gastric sleeve surgery (I was over 285lbs, my PCP thought this was causing GI issues). After gastric sleeve my usual gallbladder area pain/nausea got worse. After many ER visits, Dr R. Levy in Boca Raton started treating me for Gastroparesis with reglan/ Domperidone. Didn’t help. He referred me to Cleveland Clinic where they told me it was highly unlikely that I had Gastroparesis (not based on any medical check-up, just the doctor’s opinion). After gastric emptying test diagnosed me with moderate Gastroparesis.

I followed dietary restrictions and am mostly on soft foods. After several ER visits this year, feeling sick every day and spending most of my days in bed since I don’t have much energy left, I sought out Dr. Rosenthal at Cleveland Clinic for a gastric pacemaker (after much research). I met with Dr. Ganga and was told I was not a candidate for the pacemaker since I had sleeve surgery and that my best option would be revision to bypass. After 2 months of tests to prepare me for bypass revision surgery, I was told this week that instead of revision surgery they want to try the pacemaker after all. This confused me since I was told previously I wasn’t a candidate.

I had endoscopy 2 weeks ago and was told I also have bile reflux. After research, I read that bypass revision can help to resolve Gastroparesis issues, it can solve constant nausea and it has been proven to relief bile reflux. The pacemaker only seems to be helpful against nausea. I saw your article about Gastroparesis and would love to get your input.

Thank you!

Answer

Dear Nathali,

I have been quite fortunate over the past few years to meet and successfully treat a number of gastroparesis patients. The first patient I treated in 2010 had severe refractory gastroparesis with advanced symptoms including daily vomiting, dehydration and electrolyte abnormalities. I performed a longitudinal gastric resection that preserved the antrum and added a duodeno-jejunostomy because this particular patient had a dilated duodenum. Amazingly, he did very well. His symptoms completely resolved immediately following surgery and he was able to go back on a regular diet again. I published this case report in SOARD journal under the title of “Laparoscopic longitudinal gastrectomy and duodeno-jejunostomy for treatment of diabetic gastroparesis”.

The rationale behind this approach to treating gastroparesis is the fact that sleeve gastrectomy performed for morbid obesity has been shown to increase gastric emptying. I took this concept, modified the sleeve surgery to preserve the antrum (gastric pump) and applied it to a number of gastroparesis patients over the past few years with great success. Postoperatively, nausea, bloating, vomiting and pain resolved and gastric emptying improved.

Randomized controlled studies have shown that gastric pacing is not an effective treatment for gastroparesis. Physicians still use this approach because there are no published guidelines for treatment of gastroparesis. The theory behind gastric pacing and its presumed mechanism of action make no sense to me. I think gastric pacing is a futile and naïve approach to gastroparesis treatment.

Gastric bypass surgery may work in mild gastroparesis cases. Gastroparesis is a generalized gastro-intestinal motility disorder. Bypassing or resecting the stomach is not an effective solution for delayed gastric emptying. The few published reports about gastric bypass surgery for treatment of gastroparesis including one recently published by Dr. Rosenthal in SOARD journal: “Surgical Management of Gastroparesis: A Single Institution Experience”, show modest symptom improvement. Actually, in this report Dr. Rosenthal concludes that gastric pacing is more effective than gastric bypass at alleviating pain due to gastroparesis. Probably, this is the reason he wanted to try gastric pacing first.

Both delayed gastric emptying and the presence of a hiatal hernia increase the likelihood of gastric content reflux into the esophagus (it can be bile or acid or both). Narrowing of the sleeve lumen and large residual gastric fundus are additional risk factors for reflux. Poor esophageal motility further exacerbates reflux symptoms and reflux induced damage of the esophagus.

I recommend a comprehensive evaluation and workup before making any decision. If the sleeve can be salvaged then this would be your best option. If the sleeve cannot be salvaged then conversion to gastric bypass may help you especially if you have a mild case of gastroparesis. Gastric pacing in the setting of a gastric sleeve has not been described to the best of my knowledge and I am not sure if it will work.

Healthy Regards,

Dr. Darido