Minimal Invasive Surgical Approach for the Treatment of Gastroparesis

Joerg Zehetner, MD MMM, John C Lipham, MD, Farrokh Ravari, MD, Shahin Ayazi, MD, Afshin Skibba, MD, Ali Darehzereshki, MD, Rodney J Mason, MD, Namir Katkhouda, MD. USC Department of Surgery


Background: Gastroparesis is a chronic disorder resulting in decreased quality-of-life. The Gastric Electrical Stimulator (GES) is an alternative to gastrectomy in patients with medically refractory gastroparesis. The aim of this study is to analyze the outcomes of patients treated with the gastric stimulator versus patients treated with laparoscopic subtotal or total gastrectomy.
Methods: A retrospective chart review was performed in all patients that had surgical treatment of gastroparesis from January 2003 – June 2011. Postoperative outcomes were analyzed and symptoms were assessed with the Gastroparesis-Cardinal-Symptom-Index (GCSI).
Results: There were 93 patients: 65 patients (24 male/41 female) with GES, implanted either with laparoscopy (n=20) or mini-incision (n=45), and 28 patients (10 male/18 female) with laparoscopic subtotal (n=23), total gastrectomy (n=2) or completion gastrectomy (n=3). 30-day morbidity rate (6.2% vs. 14.3%, p=0.23) and in-hospital mortality (3.1% vs. 3.6%, p=1.00) was similar for GES and gastrectomy. In 9/65 patients (14%) with persistent symptoms the GES was explanted and a subtotal gastrectomy performed; the morbidity rate in these patients was 11.1% and no mortality. In 6/65 patients (9%) the GES was removed for infection (n=3), subjective lack of benefit (n=1) or for replacement due to pacer damage/malfunction (n=2). In the GES group there were 9 patients who died within 36 months; none of these deaths were associated with the device placement. In the gastrectomy group 1 patient died unrelated to the surgery during follow-up. Of the 54 GES patients available for follow-up (median follow-up time 24 months), 35 patients (65%) reported favorable outcome: median GCSI score was 2.33 in patients feeling better versus 3.95 in the patients who failed to respond to the GES. Of the 26 patients available for follow-up (median follow-up time 33 months) treated initially with laparoscopic subtotal or total gastrectomy, 24 patients (92%) were reporting favorable outcome: Median GCSI score was 1.89 in patients feeling better versus 4.11 in the patients who failed to respond to gastrectomy. The median GCSI score of patients with favorable outcome with the GES compared to patients with subtotal or total gastrectomy was not significantly different (1.89 vs. 2.33, p=0.30). In the 9 patients that underwent subtotal gastrectomy for failed GES, 8 patients (89%) reported a favorable outcome. Overall, favorable outcome was achieved in 68 of 80 (85%) patients available for follow-up treated with either primary GES, primary gastrectomy or secondary gastrectomy for failed GES.
Conclusion: Gastroparesis can be successfully treated by gastric electrical stimulator placement or laparoscopic gastrectomy. The gastric stimulator patients with no improvement of symptoms can be successfully treated by laparoscopic subtotal gastrectomy. We propose that the algorithm for the treatment of gastroparesis should be laparoscopic gastrectomy or mini-incision GES placement initially followed by laparoscopic gastrectomy for those that do not respond to the device.

Session Number: SS18 – Foregut
Program Number: S101

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