Question of The Week from Debbie in Houston:
“I have gastroparesis and I am not responding to medication. My GI doctor recommended that I have pyloroplasty done. While I know this will not cure the gastroparesis, what other recommendations do you have to treat it? I am meeting with the surgeon next Friday. I have a list of questions written down. What do you think I should ask him? My GI doctor told me my other options are a gastric pacemaker or eventually I am going to be put on a feeding tube. I am not holding a lot of food down. I am nauseous every time I eat, I’ve been drinking a lot of Ensure. I need some kind of relief. I don’t know what to do.”
Almost 10 years ago, I developed a procedure for a case of severe refractory gastroparesis. The patient was a 40-year-old male with constant nausea, vomiting, and abdominal pain. He was unable to tolerate any solid food and he was dependent on TPN (nutrition supplied intravenously). On day one after surgery, patient’s gastroparesis symptoms completely resolved. He was started on liquid diet and he was then successfully advanced to regular diet.
The procedure consisted of laparoscopic longitudinal gastrectomy and duodenojejunostomy. The duodenojejunostomy was added because this patient had, in addition to stomach dilation, a large and dilated duodenum. I published this case report in 2012 in the SOARD journal (https://pubmed.ncbi.nlm.nih.gov/22963822)
Over the past few years, I have applied the same concept (without the duodenojejunostomy) on around 25 cases of severe gastroparesis. Almost all patients had great outcome with complete gastroparesis symptom elimination. I have followed some of these patients for years and they remained symptom free. I have repeated gastric emptying study after surgery, and I have demonstrated normalization of gastric emptying rate. The etiology of gastroparesis in this group of patients included idiopathic, diabetic and post-surgical gastroparesis.
Consequently, I may be a bit biased when it comes to recommendations for best treatment for gastroparesis. However, mechanical drainage, like pyloroplasty and gastro-jejunostomy, of an atonic stomach are associated with poor outcome. Similarly, G-POEM (per-oral endoscopic pyloromyotomy) and pylorus Botox injection are not likely to work.
Gastric pacemakers are proven ineffective for gastroparesis treatment in randomized studies. Subtotal gastrectomy for gastroparesis has been historically associated with poor outcomes while gastric bypass studies show suboptimal results.
As a result, I believe that an antrum sparing laparoscopic longitudinal gastrectomy is currently a safe, and effective treatment for gastroparesis. Randomized and prospective studies are needed to prove my concept. In the absence of such strong evidence, my procedure is still considered experimental. However, in the absence of treatment guidelines for medically refractory gastroparesis, an antrum preserving longitudinal gastrectomy makes the most sense to me.