Pyloroplasty Revisited: A Highly Effective Treatment for Gastroparesis

Thomas W Shin, MD, Piotr Krecioch, MD, James T Dove, Marie Hunsinger, RN, Matthew E Plank, PAC, Jon Gabrielsen, MD, Anthony T Petrick, MD. Geisinger Medical Center

Introduction: Gastroparesis is a chronic digestive disorder defined by delayed gastric emptying (DGE) in the absence of mechanical obstruction. Medical treatment options are of limited efficacy and serious side effects have prompted the removal of many agents from the market. The aim of this study was to evaluate the effectiveness and safety of laparoscopic pyloroplasty (LP) for the treatment of gastroparesis.

Methods: This was a retrospective review of patients who underwent a LP for gastroparesis between May 2002 and May 2013. Patients who underwent concomitant surgical procedures were included except for patients who underwent LP for gastric outlet obstruction or with esophagectomy. All patients had gastroparesis confirmed by delayed gastric emptying study (GES) with gastric outlet obstruction excluded by EGD and/or UGI X-ray. Pre- and post-operative symptom severity score (SSS) and medication use were reviewed. GI symptoms were graded on a Likert scale. Statistical analysis was done using a Wilcoxon signed rank sum test for ordinal data, represented as a median (IQR-interquartile range).

Results: A total of 34 patients were analyzed. There was one conversion to open. Twenty patients (59%) underwent a major concomitant procedure with LP (paraesophageal hernia repair, fundoplication). Median LOS was 2 days (IQR 1-3). Median EBL was 5 ml (IQR 5, 10). At 30 days post-op there was NO mortality and NO reoperations. Readmission rate was 5.9%.

All patients had post-operative follow up at either 2 weeks or within 3 months of surgery. Post-operatively, the use of antacid (p<0.001) and prokinetic medication (p=0.03) was significantly reduced, but there was no significant reduction in the use of antiemetics (p=0.74). There were statistically significant improvements in all components of the severity scores with no significant change in diarrhea symptoms. (Table1) Post-operative gastric emptying studies normalized in 38%, were significantly improved in 44% and were unchanged or worse in 18% of patients.

Conclusion: Laparoscopic pyloroplasty is a safe and highly effective procedure for the treatment of gastroparesis. LP results in significant improvement in GI symptoms and a reduction in the use of antacids and promotility medications. There was no difference in diarrhea after pyloroplasty. The procedure can be performed safely in conjunction with additional procedures.

Table 1
Symptoms severity score Pre op (IQR) Post op (IQR) P value
Abdominal pain 1 (0, 1) 0 (0,1) <0.001
Heartburn 3 (1, 3) 0 (0, 0) <0.001
Bloating 2 (0, 2) 0.5 (0, 1) <0.001
Dysphagia 1 (0, 2) 0 (0, 1) 0.006
Regurgitation 1 (0, 2) 0 (0, 0) <0.001
Nausea/emesis 1.5 (1, 2) 0 (0, 1) <0.001
Diarrhea 0 (0, 1) 0 (0, 1) 0.61

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