Gastroparesis is a condition wherein the stomach does not empty properly. Food builds up in the stomach making the subject feel bloated, have abdominal pain, often have heartburn, and sometimes vomit. Stomach paralysis occurs when the nerves that regulate stomach functioning are damaged by disease or surgery or if the stomach itself is disordered. Diabetes is a prime cause. "The cumulative proportions developing gastroparesis over a 10-year time period were 5.2% in type 1 DM, 1.0% in type 2 DM, and 0.2% in controls."(see summary at end of this post.) Other causes include Parkinsons disease and multiple sclerosis. Amyloidosis and scleroderma can affect the stomach directly. Medications such as narcotics and some of the antidepressants can also decrease the peristalis or emptying of the stomach.
Treatment includes medications, gastric pacing, and gastric surgery. Since morbidly obese patients with diabetes often benefit from gastric bypass, gastric bypass may serve a dual purpose of weight loss and treating gastroparesis symptoms.
We have treated two patients with gastroparesis due to severe diabetes successfully with gastric bypass. I did a literature search and reprinted the following articles from the National Medical Library database. There is relatively little written about the surgical treatment of gastroparesis in the severe diabetic. I also included the summary of an article that describes gastroparesis after gastric bypass. The causes of post op gastroparesis were not described in the summary. We have not yet seen such a case in our clinical practice.
I hope you find this information useful.
Gastric bypass surgery as treatment of recalcitrant gastroparesis.
Papasavas PK1, Ng JS2, Stone AM2, Ajayi OA3, Muddasani KP4, Tishler DS2.
Few treatments for idiopathic and diabetic gastroparesis exist beyond symptom management, and no study has described gastric surgery for gastroparesis in obese and morbidly obese patients. The objective of this study was to describe treatment of recalcitrant gastroparesis in obese adults with Roux-en-Y gastric bypass (RYGB) surgery.
A retrospective review was conducted of adult patients who underwent laparoscopic RYGB. Clinical data pre- and postsurgery and at a follow-up of up to 2 years were reviewed. Total symptom scores for gastroparetic symptom severity and frequency were compared presurgery and at follow-up using paired t tests.
Seven obese and morbidly obese patients (body mass index [bMI] = 39.5, range = 33-54; 6 women) with idiopathic or diabetic gastroparesis reported marked symptom improvement, and total symptom scores significantly decreased after RYGB. All 4 patients who were taking prokinetics preoperatively no longer required their medication after surgery. Three patients required prolonged treatment with antinausea medications in the postoperative period. Mean BMI change was 9.1 units and mean percent excess weight lost was 71.6 lbs. No perioperative complications were experienced. Two required readmissions due to various concerns (dysphagia, nausea, anastomotic ulcer).
In our cohort, no patients required the use of prokinetics after surgery and everyone experienced significant improvement in symptoms. Importantly, we found that RYGB is a safe surgical treatment for gastroparesis in obese patients. Our results indicate that gastroparesis, primarily believed to result in being underweight, can present in morbid obesity and can be markedly improved with RYGB.
Copyright © 2014 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.
Gastroparesis; Roux-en-Y gastric bypass
Comment on: gastric bypass surgery as a primary treatment of recalcitrant gastroparesis. [surg Obes Relat Dis. 2014]
Surg Endosc. 2013 Jan;27(1):61-6. doi: 10.1007/s00464-012-2407-0. Epub 2012 Jun 30.
Minimally invasive surgical approach for the treatment of gastroparesis.
Zehetner J1, Ravari F, Ayazi S, Skibba A, Darehzereshki A, Pelipad D, Mason RJ, Katkhouda N, Lipham JC.
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 was to analyze the outcomes of patients treated with the gastric stimulator versus patients treated with laparoscopic subtotal or total gastrectomy.
A retrospective chart review was performed of all patients who had surgical treatment of gastroparesis from January 2003 to January 2012. Postoperative outcomes were analyzed and symptoms were assessed with the Gastroparesis Cardinal Symptom Index (GCSI).
There were 103 patients: 72 patients (26 male/46 female) with a GES, implanted either with laparoscopy (n = 20) or mini-incision (n = 52), and 31 patients (9 male/22 female) who underwent laparoscopic subtotal (n = 27), total (n = 1), or completion gastrectomy (n = 3). Thirty-day morbidity rate (8.3% vs. 23%, p = 0.06) and in-hospital mortality rate (2.7% vs. 3%, p = 1.00) were similar for GES and gastrectomy. There were 19 failures (26%) in the group of GES patients; of these, 13 patients were switched to a subtotal gastrectomy for persistent symptoms (morbidity rate 7.7%, mortality 0). In total, 57% of patients were treated with GES while only 43% had final treatment with gastrectomy. Of the GES group, 63% rated their symptoms as improved versus 87% in the primary gastrectomy group (p = 0.02). The patients who were switched from GES to secondary laparoscopic gastrectomy had 100% symptom improvement. The median total GCSI score did not show a difference between the procedures (p = 0.12).
The gastric electrical stimulator is an effective treatment for medically refractory gastroparesis. Laparoscopic subtotal gastrectomy should also be considered as one of the primary surgical treatments for gastroparesis given the significantly higher rate of symptomatic improvement with acceptable morbidity and comparable mortality. Furthermore, the gastric stimulator patients who have no improvement of symptoms can be successfully treated by laparoscopic subtotal gastrectomy.
PMID: 22752276 [PubMed - indexed for MEDLINE]
Am J Gastroenterol. 2013 Jan;108(1):18-37; quiz 38. doi: 10.1038/ajg.2012.373. Epub 2012 Nov 13.
Clinical guideline: management of gastroparesis.
Camilleri M1, Parkman HP, Shafi MA, Abell TL, Gerson L; American College of Gastroenterology.
This guideline presents recommendations for the evaluation and management of patients with gastroparesis. Gastroparesis is identified in clinical practice through the recognition of the clinical symptoms and documentation of delayed gastric emptying. Symptoms from gastroparesis include nausea, vomiting, early satiety, postprandial fullness, bloating, and upper abdominal pain. Management of gastroparesis should include assessment and correction of nutritional state, relief of symptoms, improvement of gastric emptying and, in diabetics, glycemic control. Patient nutritional state should be managed by oral dietary modifications. If oral intake is not adequate, then enteral nutrition via jejunostomy tube needs to be considered. Parenteral nutrition is rarely required when hydration and nutritional state cannot be maintained. Medical treatment entails use of prokinetic and antiemetic therapies. Current approved treatment options, including metoclopramide and gastric electrical stimulation (GES, approved on a humanitarian device exemption), do not adequately address clinical need. Antiemetics have not been specifically tested in gastroparesis, but they may relieve nausea and vomiting. Other medications aimed at symptom relief include unapproved medications or off-label indications, and include domperidone, erythromycin (primarily over a short term), and centrally acting antidepressants used as symptom modulators. GES may relieve symptoms, including weekly vomiting frequency, and the need for nutritional supplementation, based on open-label studies. Second-line approaches include venting gastrostomy or feeding jejunostomy; intrapyloric botulinum toxin injection was not effective in randomized controlled trials. Most of these treatments are based on open-label treatment trials and small numbers. Partial gastrectomy and pyloroplasty should be used rarely, only in carefully selected patients. Attention should be given to the development of new effective therapies for symptomatic control. [Ed note: this is a medical perspective.]
J Gastrointest Surg. 2007 Dec;11(12):1669-72. Epub 2007 Sep 29.
Refractory gastroparesis after Roux-en-Y gastric bypass: surgical treatment with implantable pacemaker.
Salameh JR1, Schmieg RE Jr, Runnels JM, Abell TL.
Gastroparesis is a rare complication of Roux-en-Y gastric bypass. We evaluate the role of gastric electrical stimulation in medically refractory gastroparesis.
Patients with refractory gastroparesis after gastric bypass for morbid obesity were studied. After behavioral and anatomic problems were ruled out, the diagnosis of disordered gastric emptying was confirmed by radionuclide gastric emptying. Temporary endoscopic stimulation was used first to assess response before implanting a permanent device.
Six patients, all women with mean age of 42 years, were identified. Two patients ultimately had reversal of their surgery with gastro-gastrostomy, while another had a total gastrectomy with persistence of symptoms in all three. Five of the patients evaluated had insertion of a permanent gastric pacemaker, with pacing lead implanted on the gastric pouch (2), the antrum of the reconstructed stomach (1), or the proximal Roux limb (2). Nausea and emesis improved significantly postoperatively; mean total symptom score decreased from 15 to 11 out of 20. There was also a persistent improvement in gastric emptying postoperatively based on radionuclide testing.
If medical therapy fails, electrical stimulation is a viable option in selected patients with gastroparesis symptoms complicating gastric bypass and should be considered in lieu of reversal surgery or gastrectomy.
Am J Gastroenterol. 2012 Jan;107(1):82-8. doi: 10.1038/ajg.2011.310. Epub 2011 Nov 15.
Risk of gastroparesis in subjects with type 1 and 2 diabetes in the general population.
Choung RS1, Locke GR 3rd, Schleck CD, Zinsmeister AR, Melton LJ 3rd, Talley NJ.
In patients with diabetes mellitus (DM) and upper gastrointestinal symptoms, a diagnosis of diabetic gastroparesis is often considered, but population-based data on the epidemiology of diabetic gastroparesis are lacking. We aimed to estimate the frequency of and risk factors for gastroparesis among community subjects with DM.
In this population-based, historical cohort study, the medical records linkage system of the Rochester Epidemiology Project was used to identify 227 Olmsted County, MN residents with type 1 DM in 1995, a random sample of 360 residents with type 2 DM, and an age- and sex-stratified random sample of 639 nondiabetic residents. Using defined diagnostic criteria, we estimated the subsequent risk of developing gastroparesis in each group through 2006. The risk in DM, compared with frequency-matched community controls, was assessed by Cox proportional hazards modeling.
The cumulative proportions developing gastroparesis over a 10-year time period were 5.2% in type 1 DM, 1.0% in type 2 DM, and 0.2% in controls. The age- and gender-adjusted hazard ratios (HRs) for gastroparesis (relative to controls) was 33 (95% confidence interval (CI): 4.0, 274) in type 1 DM and 7.5 (95% CI: 0.8, 68) in type 2 DM. The risk of gastroparesis in type 1 DM was significantly greater than in type 2 DM (HR: 4.4 (1.1, 17)). Heartburn (HR: 6.6 (1.7, 25)) at baseline was associated with diabetic gastroparesis in type 1 DM.
Gastroparesis is relatively uncommon in patients with DM, although an increased risk for gastroparesis was observed in type 1 DM.