Surgical Treatment of Gastroparesis

Summary

Gastroparesis is a condition in which the stomach does not empty properly. While it is initially managed with lifestyle modifications and medications, some patients eventually require surgical intervention. This study focuses on the technical considerations and surgical approaches for dealing with gastroparesis patients, which include endoscopic, minimally-invasive, and open surgical techniques.

Abstract

Gastroparesis and intestinal dysmotility are life-altering diagnoses with no cure. Lifestyle changes, pharmacological, and surgical interventions are combined in a multidisciplinary fashion to improve the quality of life in this patient population. Starting with lifestyle changes, adjustments are made to the types and amounts of food consumed, medical conditions are optimized, and the use of narcotic pain medications as well as smoking is discontinued. For many, these changes are not enough, and antiemetics and promotility agents are used to control symptoms. Finally, when these measures fail, patients turn to surgery, which can include surgical alterations to the stomach, implantation of a gastric stimulator, placement of drainage tubes, and possibly even the complete removal of different organs, including the stomach or gallbladder. In our clinic, patients not only see a surgeon but also a gastroenterologist, dietitian, and psychologist. We strongly believe in a multidisciplinary approach to this condition. The goal is to provide patients with hope and help them live fuller and happier lives.

The study primarily addresses technical considerations and the surgical approach for patients diagnosed with gastroparesis. It outlines the entire process, starting from preparations before the surgery, encompassing the preoperative work-up, and detailing the steps involved in the surgical procedure. One of the key diagnostic challenges faced in treating gastroparesis patients is determining the underlying cause of the condition, as this information is critical for selecting the appropriate surgical intervention. Once the patient's condition has been categorized based on the cause, the medical team engages in a discussion with the patient regarding potential treatment options, which may include endoscopic procedures, minimally invasive techniques, or open surgery.

Introduction

Normally, food moves through the stomach into the intestines via coordinated contractions of the stomach, which are controlled by interstitial cells of Cajal (ICC) located throughout the gastrointestinal tract. Gastroparesis is a syndrome characterized by delayed gastric emptying in the absence of mechanical obstruction and is associated with multiple symptoms, including nausea, vomiting, early satiety, abdominal bloating, and abdominal pain¹.

The most common causes of gastroparesis include diabetes, idiopathic factors, autoimmune conditions, and post-surgical situations where an injury to the vagus nerves results in pylorospasm, inhibiting the stomach's ability to empty normally. This diagnosis is significant because it profoundly impacts patients' lives, limiting their activities by 67.5%, increasing unemployment rates, and significantly reducing their quality of life^2,3,4. Healthcare systems are also affected, with gastroparetic patients experiencing a 158% increase in hospitalization and an average cost of $32,563 for inpatient stays^4,5. Therefore, it is crucial to identify and support these patients in the outpatient setting before they require hospitalization. Most importantly, it's essential to provide these patients with hope, as gastroparesis, like many other chronic diseases, cannot be cured. The best we can offer at this time is the management of patient symptoms. This article aims to summarize the approach and technical considerations for the surgical treatment of gastroparesis patients, enabling them to lead more fulfilling lives.

Symptoms
In half of gastroparesis patients, the cause of symptoms is idiopathic or unknown, while in the remaining cases, their symptoms are categorized as diabetic, post-surgical, autoimmune, or neurologic⁶. Common symptoms include nausea, vomiting, early satiety, abdominal bloating, and abdominal pain. Less common symptoms encompass changes in blood sugar levels, loss of appetite, fluctuations in weight (either loss or gain), and gastroesophageal reflux disease⁷. Older patients may exhibit differences from younger patients, experiencing more early satiety and bloating instead of nausea and vomiting⁸. It's worth noting that female patients are four times more likely to develop gastroparesis⁹.

Diagnosis, assessment, and plan
There are no physical exam findings for the diagnosis of gastroparesis. Multiple tests should be performed to confirm the diagnosis of gastroparesis. The first step is an upper gastrointestinal endoscopy for those with suspected delayed gastric emptying. In cases where the endoscopy results are negative, the next step is to establish gastric dysmotility. The gold standard for diagnosing gastroparesis is a 4 h gastric emptying study. (Previously, 2 h gastric emptying studies were recommended.) To be diagnostic for gastroparesis, 4 h gastric emptying studies should show >10% retention of a food bolus at 4 h¹⁰. These studies are exclusively used to diagnose gastroparesis, and no additional diagnoses are considered based on the results of this test. An alternative to the gastric emptying study is ¹³C breath testing using octanoate or spirulina incorporated into a solid meal, with measurement of the expiratory 13-CO₂ concentration (by mass spectrometry or infrared spectroscopy)¹¹.

An upper gastrointestinal series (UGI) with small bowel follow-through (SBFT) can also be essential when evaluating patients for a diagnosis of gastroparesis, as can CT or MR enterography when the need to limit radiation exposure arises. These are used to rule out distal obstruction, which could present as pseudo-gastroparesis, and to rule out other pathologies, including small bowel masses and strictures. Other studies of bowel function may be considered in patients with gastroparesis, such as wireless motility capsule or a SITZ marker study. These are useful to rule out other motility issues in the bowel, such as global or distal intestinal dysmotility¹².

After reviewing the patient's workup, it is important to determine which prior treatments patients have already undergone. Previous interventions, such as dietary modifications, medical optimization, and lifestyle changes, should be carefully reviewed. This includes cessation of smoking, discontinuing narcotic pain medications, and trials of anti-emetic and prokinetic agents. If patients are refractory or only partially improved with dietary modifications, medical optimization, and lifestyle changes, then surgical intervention should be considered. Surgical treatment options depend on the type of gastroparesis a patient has. For example, if a patient has post-surgical gastroparesis, they are not offered a gastric stimulator, as prior damage to the vagus nerve renders this modality futile. Otherwise, patients may be offered a gastric stimulator, pyloroplasty (either operative or endoscopic), feeding tubes, or even a subtotal or total gastrectomy.

Other previous surgical interventions also need to be considered. Patients may have had feeding tubes or other devices placed for nutrition and resuscitation, which can impact future surgical operative decisions. Additional considerations include prior endoscopies with dilation or botulinum toxin injection into the pyloric muscle. While botulinum injection is controversial, it is still widely practiced, raising concerns about scarring. This extrapolation comes from achalasia studies showing submucosal fibrosis, which could make myotomies more difficult¹³. In our practice, we tend to perform an endoscopy with dilation of the patient's pylorus using a 20 mm balloon at full volume for 1 min. This is performed to test the outcomes of stretching the pylorus before offering permanent transection.

In summary, surgical decision-making is based on a combination of patient preference, the severity of the patient's condition, and the aforementioned factors. Each of these procedures comes with unique risks and benefits associated with their approach.

Protocol

This protocol has received approval and adheres to the guidelines of the Institutional Review Board of the University of South Florida. These guidelines affirm that respect for all forms of life is an inherent characteristic of biological and medical scientists conducting research. Written informed consent was obtained from all patients prior to the procedures. The study included patients aged over 18 years with chronic, intractable (drug-refractory) nausea and vomiting resulting from gastroparesis of diabetic or idiopat…

Representative Results

After completing these surgical procedures, patients should anticipate a decrease in their overall nausea and vomiting symptoms. The progress of their symptoms is tracked using the Gastroparesis Cardinal Index Scale (GCSI)11. The technical success rate of the G-POEM procedure is 100%, with a yearly recurrence rate of symptoms at 13% or higher11. Gastric electrical stimulation is also effective in controlling gastroparesis, with improvements in GCSI nausea and vomiting. In p…

Discussion

Gastroparesis is a chronic disease for which there is currently no cure. Therefore, the primary focus of treatment is the management of symptoms. In cases where lifestyle changes, dietary adjustments, and medications do not effectively control symptoms, surgical intervention should be considered. Surgical treatment, such as pyloric surgery and/or the placement of a gastric stimulator, can significantly improve nausea and vomiting symptoms. In fact, when these two interventions are combined, they often lead to a more subs…

Materials

2-0 Sutures (absorbable)
3-0 V-loc	Medtronic		For closure of pyloroplasty
Bite Block	Endure	NBBW1-10	Mouth piece for use in endoscopy
Carr-Locke Injection Needle	Steris		Injection needle for creation of wheal
Clinical programmer	N’Vision
Coagrasper Hemostatic Forceps	Olympus	FD-411UR	For control of bleeding
Endoscopic Knife	Olympus	KD-640L	Through the scope knife used for mucostomy
Enterra Gastric leads	Enterra	4351	Leads for device
Enterra Gastric stimulator	Enterra	37800	Implantable device
HybridKnife	Erbe	20150-260 and -261	Alternative endoscopic knife