Gastroparesis in the Setting of Previous Pyloromyotomy

Gastroparesis in the Setting of Previous Pyloromyotomy

Sam from Houston sent us this question: “I am 54-year-old now, and I have suffered with delayed gastric emptying for the past 20 years. I have bloating, nausea and pain almost every day. I had a pylorus muscle surgery when I was an infant. I recently had pylorus Botox injection, but my condition did not change. My GI doc suggested a new procedure called G-POEM, but I don’t think it is going to help me. Please advise”.

Dear Sam,

You are right, G-POEM or endoscopic pyloromyotomy is not likely to promote gastric emptying to alleviate your symptoms. After all, you had a pyloroplasty as an infant most likely for pylorus hypertrophy and you failed a trial of Botox injection. Consequently, endoscopic or laparoscopic pyloromyotomy is not indicated in your case. In general, I am not a big fan of cutting pylorus muscle for gastroparesis.  The pyloric muscle in most gastroparesis patients is widely open. From a pathophysiology point of view, any procedure aiming at mechanically decompressing the stomach does not address the problem of gastroparesis. Gastroparesis or delayed gastric emptying is characterized by the lack of coordinating gastric contractions to empty gastric content in the absence of mechanical obstruction.

On the other hand, an antrum preserving longitudinal partial gastrectomy along the Magenstrasse emptying pathway results in normalization of gastric emptying. Around 40 patients in my practice at Houston Heartburn and Reflux Center have received this surgical approach with 100% success rate.  Gastroparesis patients experienced full resolution of nausea, bloating, vomiting, epigastric pain and constipation. Surgery is performed through tiny incisions. It is associated with fast recovery and low complication rate.

Today, we still don’t have a treatment guideline for medically refractory gastroparesis. Studies are needed to establish the best treatment approach to gastroparesis. I predict an antrum preserving longitudinal gastrectomy along the Magenstrasse emptying pathway will become the standard of care for gastroparesis patients in the near future.