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.

Dear Bill,

Your question is very smart, and your concern is quite appropriate. Why offer pyloroplasty for treatment of severe refractory gastroparesis when the real problem is gastric dysmotility rather than vagal nerve dysfunction and failure of pylorus muscle to relax? Gastric emptying is a highly coordinated process that doesn’t simply depend on gravity to evacuate gastric content through an open pylorus. By the same token, a gastro-jejunostomy that creates a wide connection between stomach and intestine to facilitate gastric emptying doesn’t work at all in severe gastroparesis.

Currently, there are no guidelines for treatment of severe refractory gastroparesis. Small studies published in the literature along with a general consensus among general and bariatric surgeons support either gastric bypass or pyloroplasty to treat refractory gastroparesis. The last article I reviewed for treatment of gastroparesis with gastric bypass surgery showed no symptom improvement. The study was published in Surgery for Obesity and Related Diseases journal.

Few years ago, a study showed that sleeve gastrectomy increased gastric emptying. It is thought that by resecting the stretchable part of the stomach along the greater curvature, gastric wall compliance decreases and stomach emptying increases. The mechanism of action may be more complicated since resecting the greater curvature also eliminates gastric pacemakers that play an important role in stomach motility.

Since there are no guidelines for treatment of gastroparesis and since current treatment options like gastric bypass and pyloroplasty make no sense to me, I applied the concept of sleeve gastrectomy to refractory gastroparesis cases and I had great success. I perform an antral preserving longitudinal gastrectomy. I preserve the antrum because it is the gastric pump and is a thick muscle with low wall compliance that promote gastric emptying. Most of the gastric fundus is resected. In cases of gastroparesis after Nissen fundoplication, I preserve the fundoplication and resect the greater curvature between the fundoplication and antrum. Unfortunately, my experience is limited to less than 10 cases, but the outcome of my approach has been great. All symptoms of gastroparesis completely and immediately resolved following surgery in all patients I operated on.

For these reasons, I am not a fan of pyloroplasty and I am completely opposed to offering gastric bypass for treatment of gastroparesis. Hopefully, future studies will help further delineate the best approach to management of refractory gastroparesis.