GASTROPARESIS

Gastroparesis, also called delayed gastric emptying, is a medical condition consisting of a paresis (partial paralysis) of the stomach, resulting in food remaining in the stomach for a longer period of time than normal in the absence of obstruction. This condition is thought to affect about 4% of the population. Approximately 40% of patients have no definite cause for their condition and are classified as Idiopathic. About 33% of patients have long-standing diabetes. The remaining patients have either a history of gastric surgery resulting in a vagal nerve injury or other unusual medical conditions.

SYMPTOMS

  • Nausea
  • Vomiting, especially vomiting undigested food a few hours after eating
  • Feeling of fullness even after eating very little
  • Acid reflux or heartburn
  • Abdominal pain and/or bloating
  • Changes in blood sugar levels
  • Lack of appetite and malnutrition
  • Weight loss

DIAGNOSIS

  • Gastric Emptying Study This is the most important test used in making a diagnosis of gastroparesis. It involves eating a light meal, such as eggs and toast, that contains a small amount of radioactive material. A scanner that detects the movement of the radioactive material is placed over your abdomen to monitor the rate at which food leaves your stomach. You’ll need to stop taking any medications that could slow gastric emptying. Ask your doctor if any of your medications might slow your digestion.
  • Upper Gastrointestinal (GI) Endoscopy This procedure is used to visually examine your upper digestive system — your esophagus, stomach, and beginning of the small intestine (duodenum) — with a tiny camera on the end of a long, flexible tube (Video-endoscopy). This test can also diagnose other conditions, such as peptic ulcer disease or pyloric stenosis, which can have symptoms similar to those of gastroparesis.
  • Upper Gastrointestinal Series This is a series of X-rays in which you drink a white, chalky liquid (barium) that coats the digestive system to help abnormalities show up.
  • Proximal Gastric Bypass to Distal Gastric Bypass

TREATMENT OPTIONS

Traditionally, the management of gastroparesis has relied on maintaining a high carbohydrate type of diet with small meals. For patients with more severe disease, they have generally been treated with a gastrostomy tube to drain the stomach and a jejunostomy feeding tube to provide supplemental nutrition. More recently, there has been an increasing role for the surgeon in the management of Gastroparesis. This is a complex issue as the surgical strategies to manage the different types of patients with the available procedures are not well established. Very few gastroenterologist and surgeons have been interested in this patient population and, therefore, there is limited published data to direct surgical treatment. Based on the current data, I offer four different surgical procedures to manage my patients with Gastroparesis.

  • Laparoscopic Pyloroplasty: A sub-group of gastroparesis patients can benefit from a simple pyloroplasty procedure to cut the outlet of the stomach. In my practice, I recommend that patients with idiopathic or post-gastric surgery gastroparesis undergo an EGD and pyloric botox injection as a trial of therapy. If they experience subjective improvement in their symptoms and normalization of their gastric emptying on a repeat Gastric Emptying Study, then a pyloroplasty procedure may be sufficient to treat their condition.
  • Laparoscopic Gastric Stimulator “Enterra Therapy”: This option is well suited to patients with diabetic gastroparesis who have predominantly nausea and vomiting symptoms. It has been associated with about 80% improvement in their symptom scores. However, at present, there is no way to predict which patients will be responsive to this therapy. It is important to understand that the stimulator typically does not improve pain symptoms. In my practice, I no longer offer the stimulator to patients who have a significant pain component to their symptoms. In addition, the outcomes for patients with idiopathic gastroparesis are not much better than placebo and I am reluctant to offer this treatment option to those patients. Unfortunately, the technology is expensive and the benefits, while real, are too unpredictable at this time to be offered to patients with little chance of benefit. Therefore, I only offer this option to my diabetic gastroparesis patients.
  • Laparoscopic Sub-total Gastrectomy: This is the both the most aggressive and reliable option to manage all sub-groups of gastroparesis. It is counter-intuitive to most observers that the best therapy would be to remove most of the stomach. One must understand that patients with gastroparesis have a very difficult time eating due to the associated symptoms that are associated with meals. The surgery enables them to eat small amounts with minimal or no nausea. Most patients (85-90%) will experience benefit from this surgery. More importantly, in the era of Minimally Invasive Surgery, this option is associated with much less risk than before. My patients typically leave the hospital within two days and are back to their normal lives in 1-2 weeks.
  • Laparoscopic Vertical Sleeve Gastrectomy: There is anecdotal evidence that this may have a role in the management of gastroparesis. This is based upon the experience with diabetic morbidly obese patients who have this procedure to manage their obesity. In addition to their weight loss, the procedure has been associated with resolution of nausea symptoms. There is empirical evidence that this operation results in faster gastric emptying in the obesity surgery population. However, its potential role in the primary management of gastroparesis in normal weight patients is still not certain.

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