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.