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End of the Road for a Dysfunctional End Organ: Laparoscopic Gastrectomy for Refractory Gastroparesis

  • 2014 SSAT Plenary Presentation
  • Published:
Journal of Gastrointestinal Surgery

Abstract

Introduction

Gastroparesis is a functional disorder resulting in debilitating nausea, esophageal reflux, and abdominal pain and is frequently refractory to medical treatment. Therapies such as pyloroplasty and neurostimulators can improve symptoms. When medical and surgical treatments fail, palliative gastrectomy is an option. We examined outcomes after gastrectomy for postoperative, diabetic, and idiopathic gastroparesis.

Methods

A prospective database was queried for gastrectomies performed for gastroparesis from 1999 to 2013. Primary outcomes were improvements in pre- versus postoperative symptoms at last follow-up, measured on a five-point scale. Secondary outcome was operative morbidity.

Results

Thirty-five patients underwent laparoscopic total or near-total gastrectomies for postoperative (43 %), diabetic (34 %), or idiopathic (23 %) gastroparesis. Antiemetics and prokinetics afforded minimal relief for one third of patients. There were no mortalities. Six patients suffered a leak, all treated with surgical reintervention. With a median follow-up of 6 months, nausea improved or resolved in 69 %. Chronic abdominal pain improved or resolved in 70 %. Belching and bloating resolved for 79 and 89 %, respectively (p < 0.01).

Conclusions

Regardless of etiology, medically refractory gastroparesis can be a devastating disease. Near-total gastrectomy can ameliorate or relieve nausea, belching, and bloating. Chronic abdominal pain commonly resolved or improved with resection. Despite attendant morbidity, gastrectomy can effectively palliate symptoms of gastroparesis.

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Acknowledgments

Our thanks go to Shelane Oglesby, Julian Kousol, Maria Cassera, Angi Gill, and Lisa Leeth for their assistance in data collection, maintenance of the database, and administrative study support.

Financial Disclosure

No support or funding was obtained for this study.

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Authors and Affiliations

Authors

Corresponding author

Correspondence to Neil H. Bhayani.

Additional information

Discussant

Dr. Steven R. DeMeester (Los Angeles, CA): I would like to congratulate the authors on a very interesting study on a difficult topic. I have several questions. The first is on the definition of delayed gastric emptying. Given the duration of the study with patients dating back some 15 years or so, how has the definition of delayed gastric emptying changed, and do you think that impacted the results?

Secondly, what did you do with the remnant stomach in these patients? Was it left intact similar to a bariatric procedure, or was it removed? If it was done differently in patients, did it seem to make a difference whether it was removed or left in place?

The third question relates to the patients that had prior fundoplications. Did you ever leave the fundoplication in place and do the gastrojejunostomy just below the intact fundoplication? If not, and the fundoplication was removed and an esophagojejunostomy performed, did these patients have difficulties with regurgitation given the presumably weak or absent lower esophageal sphincter at that point?

Lastly, I have a question about the outcome in these patients. While most of the patients were females, there were some men. It has been my personal experience that men are much less happy without a stomach, whereas oftentimes, women do not seem to be as troubled. Did you note any differences in satisfaction or outcome between men and women after gastrectomy?

Thank you and, again, congratulations on a very interesting study.

Closing Discussant

Dr. Bhayani: Thank you for the excellent questions and the opportunity to elaborate on some of our data. In our database, the means of diagnosing gastroparesis is not specified. The patients were evaluated in our specialized foregut referral practice. Their diagnosis was assigned by our physicians after verifying or repeating previous diagnostics. However, as the criteria for diagnosing gastroparesis has evolved from using the “t½” to using the “4-h emptying” metrics, our practice has followed.

In all these patients, we performed a resection of the stomach. Regardless of total or subtotal, the remnant was removed. Relatedly, we tended to leave intact fundoplications alone and transect the stomach below the fundoplication. If the fundoplication was not intact, it was taken down prior to resection. Because we try to avoid the morbidity of an esophagojejunostomy, most patients had a subtotal gastrectomy. Unfortunately, we do not have the sample numbers to compare regurgitation or reflux between patients who underwent total versus subtotal gastrectomy with fundoplication.

Our population of refractory gastroparetics was predominantly female. There were no apparent differences between genders in symptom scores or symptom resolution. However, due to the limited numbers of men, it would not be an adequately powered comparison.

Thanks again to the society, the moderator, and my co-investigators for the privilege to present our data and findings.

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Bhayani, N.H., Sharata, A.M., Dunst, C.M. et al. End of the Road for a Dysfunctional End Organ: Laparoscopic Gastrectomy for Refractory Gastroparesis. J Gastrointest Surg 19, 411–417 (2015). https://doi.org/10.1007/s11605-014-2609-y

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  • DOI: https://doi.org/10.1007/s11605-014-2609-y

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