I was asked to review a study titled “Laparoscopic Treatment of Gastroparesis: A Single Center” submitted for publication in SOARD (Surgery for Obesity and Related Diseases). It is a single center, retrospective study. The charts of 93 patients with either idiopathic or diabetic gastroparesis were reviewed over a period extending from 2003 till 2014. Most patients were treated with gastric electric stimulator implantation. 15 patients underwent Roux-en-Y gastric bypass surgery.
The authors showed that gastric bypass surgery unlike gastric electric stimulation is not associated with statistically significant improvement in vomiting and pain. They also showed that 40% of operated patients continued to use an antiemetic and or pro-kinetic medication after either gastric bypass or gastric electric stimulation. 18% of patients required reoperation. Most of those patients underwent gastric electric stimulator removal. The authors conclude that surgery is feasible and effective for gastroparesis treatment. Although both procedures have some degree of efficacy, Gastric Electric Stimulation seems to provide improvement of more gastroparesis symptoms.
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.
Randomized, prospective controlled studies have clearly shown that gastric electric stimulation showed no symptom 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.
I disagree with the author’s conclusion stating that gastric bypass and electric stimulation are effective surgical solutions for gastroparesis. According to this study, gastric bypass did not alleviate vomiting and pain and gastric electric stimulation, GES, showed symptom improvement in around 60% of patients. GES and gastric bypass procedures have therefore limited efficacy in gastroparesis management.
I think it is very important for general and bariatric surgeons to understand that gastric bypass surgery is not a good option for medically refractory gastroparesis cases. I have developed a procedure for treatment of gastroparesis, few years ago, based on published reports showing improved gastric emptying following gastric sleeve surgery. A longitudinal gastrectomy or modified sleeve gastrectomy that preserves the gastric antrum (stomach pump) and leaves some gastric fundus (especially for the malnourished patients) has been amazingly effective for gastroparesis treatment in my private practice. I have used this approach in around 10 patients with great results. These patients had complete resolution of all gastroparesis related symptoms including nausea, vomiting and abdominal pain. Any outcome short of complete symptom resolution should not be labeled as “effective”.
Resecting the greater curvature while preserving the gastric antrum has a real potential for being a breakthrough treatment for this poorly understood disorder. Prospective randomized studies evaluating the modified sleeve gastrectomy for gastroparesis treatment are needed to help us improve our care of this medical condition.