Laparoscopic Pyloroplasty Is a Safe and Effective First Line Surgical Treatment for Refractory Gastroparesis

Amber L Shada, MD1, Radu Pescarus, MD2, Christy M Dunst, MD3, Maria A Cassera, MD3, Emily Speer, MD1, Kevin M Reavis, MD3, Lee L Swanstrom, MD3. 1Providence Portland Medical Center, 2Universite de Montreal; Sacre Coeur Hospital, 3The Oregon Clinic

Introduction

Gastroparesis is a syndrome characterized by nausea, vomiting, bloating, and abdominal pain in the setting of delayed gastric emptying. Dietary modifications and various medical therapies of gastroparesis are rarely effective. Surgical options for delayed gastric emptying include gastric stimulator implantation, feeding jejunostomy or venting gastrostomy, subtotal gastrectomy, and pyloroplasty. Pyloroplasty has long been shown to improve gastric emptying yet is seldom described as a primary treatment for gastroparesis. We present a single institution experience of laparoscopic Heineke-Mikulicz pyloroplasty (LP). Our aim was to evaluate the indications, effectiveness, and morbidity for LP.

Methods and Procedures

A prospective foregut surgery database was queried for LP over a 5-year period. Charts were reviewed for indications, complications, symptom score (SS) and outcomes. Gastroparesis was defined by 1) abnormal gastric emptying study (GES) 2) endoscopic visualization of retained food after prolonged NPO status or 3) clinical symptoms suspicious for vagal nerve injury following complex re-operative foregut surgery. Preoperative and postoperative 0-4 ordinal SS, GES, and clinical data about postoperative morbidity including readmission, leak, and return to OR were collected and analyzed using a paired T test.

Results

One hundred and sixty LP patients were identified and reviewed. Eighty-eight (55%) had a concurrent fundoplication for objective reflux. There were no intraoperative complications or conversions to laparotomy. Overall morbidity rate was 6.8%, with 1 return to OR for a confirmed leak (0.6% leak rate). Average length of stay was 3.5 days, and readmission rate was 7%. Eighty-nine percent had improvement in GES with normalization in 77%. Gastric emptying half-time decreased from 168 ± 94min to 91.4 ± 45 min. Nine percent of patients had subsequent surgical interventions: feeding jejunostomy tube (6), gastric stimulator implantation (9), or subtotal gastrectomy (5). Symptom severity scores decreased significantly at 3 months. (Table 1).

Conclusions:

LP improves or normalizes gastric emptying in nearly 90% of gastroparesis patients with very low morbidity. It significantly improves symptoms of nausea, vomiting, bloating, and abdominal pain. Some patients may go on to another surgical treatment for GP, but LP appears to have a clear role in the treatment algorithm of gastroparesis in patients with refractory symptoms.

Table 1.
Preop Postop P Value
Nausea 2.4 1.8 0.002
Vomiting 1.4 0.5 0.001
Bloating 1.8 1.0 0.001
Abdominal Pain 1.9 1.4 0.009
Early Satiety 1.6 1.2 0.04

Subjective Symptom Score was quantified during patient interview both before and 3 months after LP. The score is for frequency of symptoms: 0- never; 1- rarely/1-2 times monthly; 2- occasionally/1-2 times weekly; 3- frequently/daily; 4- daily/continuous

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