I am sharing a letter I received from a patient overseas to shed light on a prevalent yet poorly understood disease that significantly affects the quality of life of millions of people around the world. Hundreds of patients in Houston suffer from gastroparesis or delayed gastric emptying. There are no effective medications that promote gastric emptying. Severe gastroparesis like this case is particularly debilitating and hard to live with.
“Dear Dr. Elias Darido,
I would appreciate it if you could kindly give me an opinion on my wife’s severe gastroparesis. On April the 7th 2016 she underwent hiatoplasty and Nissen fundoplication surgery for reducing her hiatal hernia. Unfortunately, after this surgery she suddenly had a severe gastroparesis (evidenced by an X-ray scan with gastrografin as a contrast medium). For almost two months – non continuatively – she has been treated with the following drugs: Ursodesossicolic acid (UDCA) 450 mg (1/die); Domperidone (2/die) Butyric acid (colonlife) (1+1/die) And eating a semi-liquid diet No improvement was achieved. In June she started to take: resolor prucalopride 2 mg (1/die), for two weeks, and at the same time erythromycin 1000 mg x2 die, for one week. Still no improvement was achieved. In July she was still feeling pain and so she could not eat, if not after a digestive process taking three days to complete. She experienced significant weight loss: from the 68 kg she weighed in April before the surgery, she now was 55 kg in July. (Height 168 cm; 49 years old) After several consultations by many doctors, the 12th of July 2016 she has been treated with a laparascopic surgery consisting of: Gastric-resection and Roux-en-Y anastomosis; However, after six days due, to surgery complications she underwent a further “laparascopic explorative surgery + adhesiolysis” She then progressively started to eat a liquid diet, a semi liquid diet, taking resolor prucalopride 1 mg (2/die) and erythromycin 500 mg (2/die) but nothing worked, the remaining 50% of her stomach is very dilated and eventually she had to stop eating, still having a severe gastroparesis. Since the 5th of August she had been only fed through parenteral nutricion. Nothing has changed, but even worse! She weighs 50 Kilos now. … I thank You very much for the attention and for the time you have dedicated to read this letter.”
Medically refractory gastroparesis patients often resort to surgery. There is however no consensus in the surgical community on what procedure to use for treatment of severe gastroparesis. Some advocate a pyloroplasty especially in the setting of a Nissen fundoplication. Others support the use of gastric bypass surgery as a mean of allowing food to bypass the paralyzed stomach. Personally, I don’t think that simple gastric drainage like a pyloroplasty or gastro-jejunostomy is a good treatment for gastroparesis. Similarly, Roux-en-Y gastric bypass surgery does not address the underlying problem. The dilated gastric remnant continues to cause the same symptoms of pain, bloating and inability to tolerate regular diet. Historically a subtotal gastrectomy has been performed for refractory gastroparesis. The procedure is quite invasive and is associated with poor outcomes and decreased survival. The lesson I learned from reviewing the literature and studying these cases is that resecting or bypassing the stomach is not a good solution for gastroparesis. Rather, partial gastric resection mainly involving the gastric fundus and greater curvature results in improved gastric emptying and symptom resolution in all 6 cases I have so far performed.
I call the procedure I have developed for treatment of gastroparesis modified gastric sleeve surgery or a longitudinal gastric resection. I perform a greater curvature resection including most of the gastric fundus while preserving the antrum. The antrum is the gastric pump and does not seem to contribute to gastroparesis. I have applied this technique on 6 patients so far with great success. Two of those patients have developed gastroparesis following Nissen fundoplication. Historically, gastroparesis following fundoplication surgery has been attributed to vagal nerve injury. I think, however, that these patients had an underlying element of gastroparesis contributing to acid reflux. Possible vagal nerve injury has most likely worsened the underlying gastroparesis issue.
I have been taken care of a young man with severe gastroparesis for the past one year. He had a Nisen fundoplication 6 years ago for presumed GERD. A year ago, he underwent revision surgery for presumed twisted wrap. His Nissen fundoplication was converted to a Toupet. He has continued however to have the same epigastric pain and bloating and presented to my office for a second opinion. I ordered a gastric emptying study that confirmed gastroparesis. An upper endoscopy showed large amount of solid food residue in the stomach. I tried a number of prokinetic medications with no success in alleviating his symptoms. Finally, I offered him the modified sleeve gastrectomy. The stomach was resected along the greater curvature starting at the junction between the antrum and gastric body. The Toupet fundoplication was left intact and most of the gastric body was resected while preserving the antrum. Patient symptoms improved readily after surgery and a post-operative contrast study showed accelerated contrast emptying from the stomach into the duodenum. It has been 3 months now and he continues to do very well.
The modified gastric sleeve procedure for treatment of gastroparesis deserves to be thoroughly evaluated as a potential cure for gastroparesis. There has been very little progress made in our understanding of gastroparesis and gastrointestinal motility disorders in general. Obesity, type 2 diabetes and gastroesophageal reflux disease are closely associated with gastrointestinal motility malfunction. It is time for the medical community to start investing time, energy and money in figuring out these motility disorders and their impact on very common diseases that have reached epidemic level in our society.