Surgical Treatment of Medically Refractory Gastroparesis in Morbidly Obese Patients

Zhuo Sun, MD, John Rodriguez, MD, John McMichael, Bipan Chand, MD, Stacy Brethauer, MD, Phillip Schauer, MD, Kevin El-Hayek, MD, Matthew D Kroh, MD. 1 Digestive Disease Institute, Cleveland Clinic, Cleveland, OH; 2 Department of Surgery, Loyola University, Maywood, IL.

Introduction: The management of medically refractory gastroparesis remains a challenge. In addition to decompressive and feeding tube placement, additional surgical options for these patients include gastric electrical stimulation (GES) and near-total gastrectomy with Roux-en-Y reconstruction (NTG). Case series and smaller retrospective series describe clinical benefits from surgical intervention; however, no study reports the efficacy of GES or NTG in morbidly obese patients with severe gastroparesis. The aim of this study was to analyze the outcomes of morbidly obese patients treated with GES and NTG for gastroparesis.

Methods: A retrospective chart review was performed to identify all morbidly obese patients (Body Mass Index >35 kg/m2) who underwent GES or NTG for medically refractory gastroparesis from March 2001 to December 2011 at the Cleveland Clinic. The main outcomes examined were symptom improvement, postoperative complications, and change in Body Mass Index (BMI).

Results: A total of 24 morbidly obese patients underwent surgical treatment for severe gastroparesis. Among them, 17 patients (12 female/ 5 male) had GES placement and 7 patients (6 female/ 1 male) had NTG. All operations were completed laparoscopically. The thirty-day morbidity rate was lower for GES than NTG, but this result was not statistically significant (5.9% vs 14.3%, p=0.5). Early complications included one infection at a simultaneously placed J-tube site in the GES group, and one duodenal stump leak in the NTG group. There were no mortalities in either group. At follow-up in the GES group, 15 patients (88%) rated their symptoms as improved versus 7 (100%) in the NTG group (p=0.35). Four patients who failed GES were subsequently converted to NTG and had 100% short-term symptom improvement. The BMI change after GES implantation was 0.7±4 kg/m2 versus -6.7±3.9 kg/m2 in the NTG group (p<0.01).

Conclusion: GES implantation and NTG appear effective in treatment for medically refractory gastroparesis in morbidly obese patients. Both options can be performed in a minimally invasive fashion with low morbidity. Patients who have no improvement of symptoms for refractory gastroparesis after GES implantation can be successfully converted laparoscopically to NTG.

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