Simultaneous Versus Staged Operations for Gastroparesis: Does Timing of Laparoscopic Feeding Jejunostomy and Gastric Electrical Stimulator Matter?

Mena Boules, MD1, Gautam Sharma, MD1, Hideharu Shimizu, MD, PhD2, Ryan Plescia, PAC1, James Villamere, MD1, Dvir Froylich, MD1, John Rodriguez, MD1, Matthew Kroh, MD1, Kevin El-Hayek, MD3. 1Cleveland Clinic, 2Tokyo Metropolitan Tama Medical Center, 3Cleveland Clinic- Abu Dhabi

Introduction: Gastroparesis is a chronic, debilitating motility disorder for which gastric electrical stimulation (GES) has shown efficacy. Patients often also require adjunctive nutritional support via jejunostomy tube (j-tube). Combining these two operations may theoretically increase overall morbidity, especially in relation to infectious complications. This study aims to assess staged versus simultaneous procedures for laparoscopic enteral access, and GES placement.

Methods: 185 patients who underwent laparoscopic GES placement at the Cleveland Clinic from 2001 to 2015 were analyzed retrospectively. 124 received GES only never requiring j-tube, and were excluded from analysis. The remaining 61 patients who had both GES and j-tube placement were analyzed. Data collected included demographics, nutritional outcomes, j-tube related outcomes, and clinical parameters. Descriptive statistics were computed for all factors. A P value <0.05 was considered statistically significant.

Results: A total of 61 patients (n=52, female; n=9, male) met the inclusion criteria. Mean age was 39.5 ± 12.0 years, BMI 25.7 ± 7.2, and there was no difference between groups. Mean albumin prior to any surgical intervention was 4.2 ± 0.5 g/dL. Mean albumin levels 6 months post-j-tube placement was 4.0 ± 0.6 g/dL. There were no major intra-operative complications or mortalities reported in any group. 27 had diabetic gastroparesis and 34 idiopathic. Post-surgical gastroparesis patients do not undergo GES at our institute. According to when patients underwent j-tube placement patients were divided into 3 groups, group A (n=13 (21.3%), j-tube placement prior to GES), group B (n=29 (47.5%), concomitant j-tube and GES placement), and group C (n=19 (31%) j-tube placement post-GES). Rate of wound infection at site of j-tube was 0, 4/29(14%), and 6/19(31.5%) in groups A, B, and C.  Mean operative duration in group B was 113.0 ± 20.0 minutes. Although not statistically significant, 30-day readmission rates related to j-tube complications were analyzed, groups B, and C displayed a 31% and 26.3% readmission rate, whereas group A demonstrated 0% readmission. There were no generator or lead infections in any group.

Conclusion: The concomitant placement of j-tube during GES implantation is safe and feasible, with no device related infections or complications. This approach may eliminate the need for a second. For unclear reasons j-tube complications were higher in groups undergoing combined procedures and j-tube placement after previous GES. 

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