Question of the Week: G-POEM for Gastroparesis

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”

Is Pyloroplasty a Reasonable Solution 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?”

How Do I Manage Advanced Gastroduodenoparesis?

How Do I Manage Advanced Gastroduodenoparesis?

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?”

Question of the week: What Would You Do for This Gastroparesis Case?

“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.

Persistent Gastroparesis Following Gastric Sleeve Surgery

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

Gastric Pouch Emptying Following Gastric Bypass Surgery

Gastric Pouch Emptying Following Gastric Bypass Surgery

Sarah Stano et al, at the obesity nutrition research center, Columbia University, New York, have recently published an Excellent new study in SOARD journal. The authors evaluated the effect of meal size and texture on gastric pouch emptying as well as GLP-1 secretion following gastric bypass surgery. Continue reading “Gastric Pouch Emptying Following Gastric Bypass Surgery”

Question of the Week from Tina

Question of the Week from Tina:

I’m planning on having VSG in the next three months. I had the Nissen funoplication 3 yrs ago for severe Gerd. My consult will be sometime next month. It seems that there is no contraindication for gastric sleeve after the nissen procedure, according to this article which is a relief to me. It seems nissen reversal prior to VGS would be a much riskier procedure. Will there be enough of the “hunger hormone” side of the stomach to surgically remove and can this side of stomach grow back? Or does it just stretch itself back out if one tends to over eat?

Excellent question Tina. Ghrelin or hunger hormone is mostly secreted by gastric fundus. Ghrelin blood level decreases following gastric sleeve surgery as the gastric fundus is resected. Decreased ghrelin levels contribute to hunger control, increased satiety and weight loss. We don’t have any study evaluating Ghrelin blood level following Nissen Sleeve surgery. I think that a plicated gastric fundus is metabolically equivalent to a resected fundus. Therefore, I expect Ghrelin level to decrease following Nissen Sleeve surgery. Nissen fundoplication is associated with weight loss and a recent study published in 2015 demonstrated decreased Ghrelin levels following fundoplication surgery. Gastric fundus invagination, a weight loss procedure I developed few years ago, prevents Ghrelin level increase with weight loss. I demonstrated this finding in an obese rat model. In humans, gastric fundus invagination has not been studied but I predict that Ghrelin levels will also decrease.

Ghrelin, however, is not the only hormone change responsible for weight loss. Many other signals are equally important like GLP-1 (Glucagon like peptide). GLP-1 decreases following Nissen fundoplication and is likely to decrease following Nissen Sleeve surgery. Increased gastric emptying is thought to contribute to GLP-1 increase and Nissen fundoplication is associated with increased gastric emptying. I have noticed on post-operative contrast studies that Nissen Sleeve procedure increases gastric contrast emptying.

Overall, I think that the plicated fundus is functionally equivalent to a resected fundus. When properly performed, fundus presrving gastric sleeve surgery, in obese patients with history of Nissen fundoplication, results in excellent weight loss results.

Laparoscopic Treatment of Gastroparesis: A Single Center Experience

A new study on gastroparesis treatment was recently accepted for publication in SOARD (Surgery for Obesity and related Disorders) journal. The study is a retrospective, single center, evaluation of 15 vs 73 patients who underwent gastric bypass vs gastric electric pacing surgery for treatment of medically refractory gastroparesis. The authors attempt to analyze the effectiveness of each procedure by studying post-operative symptom improvement and anti-emetic medication use. The results indicate nausea resolution but no improvement in vomiting and pain and no reduction in medication use following gastric bypass. Gastric electric pacing improved nausea, vomiting and abdominal discomfort but medication use did not change. Such finding suggests that symptoms did not really improve following gastric pacing and patients continued to require pro-kinetic and anti-emetic medications.

These results are in accordance with previously published literature. Randomized, prospective controlled GES showed no improvement in gastroparesis patients. RYGB is not well studied for gastroparesis treatment. In my personal experience, I have seen no improvement of gastroparesis symptoms following RYGB especially in severe and medically refractory cases. A longitudinal gastrectomy, on the other hand, that preserves the gastric antrum has been quite effective for gastroparesis treatment. I have had great success in my private practice treating around 10 patients with severe gastroparesis. All gastroparesis related symptoms completely resolved immediately following surgery with no readmission over more than one year follow up.

Gastroparesis incidence is rising and we still don’t have a good understanding of its pathophysiology. Most importantly, there is no established effective treatment guidelines for gastroparesis. Many gastroparesis patients are left untreated or poorly treated with symptoms that significantly diminish their quality of life and overall health. A multidisciplinary and serious effort is needed to study this disease to establish a treatment protocol. Studies like the one currently published in SOARD clearly show the ineffectiveness of gastric pacing and gastric bypass surgery for treatment of gastroparesis. The authors, however, seem hesitating confirming this observation and rather conclude that both procedure offer some degree of symptomatic improvement. Some degree of improvement is simply not enough when it comes to gastroparesis treatment.

G-POEM for Gastroparesis Treatment

G-POEM for Gastroparesis Treatment

I read with great interest this study by Khashab MA et al, titled “Gastric per-oral endoscopic myotomy (POEM) for refractory gastroparesis: results from the first multicenter study on endoscopic pyloromyotomy” and published in the journal of Gastrointestinal Endoscopy. The authors analyze the outcome of endoscopic pyloromyotomy in 30 patients with refractory gastroparesis.

The technique is adopted from POEM procedure used for achalasia treatment. It is an endoscopic intra-mural approach to cutting the pyloric sphincter muscle in hope of promoting gastric emptying. This approach while appealing and apparently feasible is not likely to improve gastroparesis. The authors, however, report that around 80% of patients had improvement or normalization of their gastric emptying rates.

Gastroparesis is a poorly understood gastro-intestinal motility disorder with no clear treatment guidelines. Drainage procedures in the form of a pyloroplasty or gastro-jejunostomy rarely works. Unless gastric motility is partially or completely restored, physical drainage of gastric lumen by widening the gastric outlet is unlikely to resolve symptoms.

We have developed a laparoscopic procedure that entails resecting the greater curvature of the stomach while preserving the antrum for treatment of severe refractory gastroparesis. The procedure is similar to a sleeve gastrectomy and does not alter gastric outlet size or function. Our success rate has been very high in our series of 10 patients. It is possible to restore gastric motility by resecting the greater curvature. Endoscopic procedures are quite attractive. If, however, they don’t make sense from a pathophysiologic point of view, they are not likely to work. There is a general trend these days to rapidly adopt new endoscopic approaches. Endoscopic surgery is least invasive but not necessarily most effective. G-POEM while feasible and safe is not likely to be a solution for gastroparesis.