Surgical management of gastroparesis

Introduction

Gastroparesis (GP) is a disorder of delayed gastric emptying in the absence of mechanical obstruction that manifests with abdominal pain, nausea/vomiting, bloating and early satiety. Total or subtotal gastrectomy is indicated only as the final step in the GP subset of patients (<5%) whose vomiting has not responded to all medical therapies including PP and GES. However, extensive gastric resection surgery has complications, including long-term nutritional challenges, limiting its application . In those patients refractory to standard initial medical therapy affecting 30% of patients, then combining PP with GES is one consideration as the next best choice and approach currently recommended, with the main goal being to accelerate gastric emptying as well as addressing continuing nausea . Tailored approaches with staged care ranging from initial enteral support to simultaneous GES/PP are the preferred options for organ-sparing surgery in this population that suffers from chronic ongoing symptoms as well as malnutrition .

Enteral access: decompression and feeding

Enteral access is the first stage in the treatment paradigm for rescuing patients from chronic malnutrition and recurring hospital admissions (please also refer to Chapter 29 for definitive information on use of enteric tube placement in patients with gastroparesis).

Gastrostomy tubes

These tubes can prevent symptoms of nausea and vomiting in GP and reduce hospitalization rates by a factor of 5 during the year after placement by venting the stomach and allowing drainage of gastric contents . Venting functions can be complicated by electrolyte imbalances and malnutrition. Per-endoscopic gastrostomy (PEG) with jejunostomy extension (PEG-J) can provide dual drainage and feeding functions. Complications include migration of the J-tube extension back into the stomach and pyloric obstruction related to the tube also sharing the pyloric canal lumen . Gastrostomy tubes can be placed endoscopically or surgically using a wide variety of techniques listed in order below of complexity and feasibility:

• 1.

  Gastrostomy-laparotomy technique. This is most commonly combined with concomitant procedures or in cases where inflammatory conditions or repeat surgeries prevent safe endoscopic or laparoscopy-assisted access.

• 2.

  PEG-pull technique. First introduced by Ponsky in 1980, this technique utilizes the gastroscope for insufflation of the stomach to allow palpation and entry of a needle percutaneously using “safe tract” technique to advance a guide wire into the stomach and pull a gastrostomy tube through the mouth and esophagus to exit the anterior stomach .

• 3.

  PEG-push technique. This technique utilizes a stiff wire to advance a gastrostomy that is pushed through the stomach and abdominal wall under endoscopic vision .

• 4.

  PEG-introducer technique. This technique utilizes the Seldinger technique for sheath entry into the stomach with dilation and percutaneous entry of the tube over a wire under endoscopic visualization. The technique is associated with complications from accidental dislodgment, gastrointestinal perforation and tube site infection .

• 5.

  Laparoscopic-Assisted PEG (LA-PEG). This is utilized in those where PEG was not successful secondary to a lack of accurate visualized safe gastric access. Laparoscopy begins with visual access to examine for evidence of inadvertent intestinal injury. The pull PEG technique is then utilized under laparoscopic visualization to ensure safe entry into the stomach .

• 6.

  Laparoscopic gastrostomy. Comparable to open gastrostomy, this is often done in the setting of concomitant procedures. Gastric access is achieved by placing a purse-string suture in the avascular portion of the greater curvature of the body, followed by sharp entry into the stomach using a harmonic scalpel, and insertion of a balloon-tipped feeding catheter. Trans-abdominal sutures may be used to Stamm or suture the stomach to the anterior abdominal wall. Placement of Moss-type feeding tubes or dual lumen tubes are not feasibly accomplished due to a lack the ability to guide the tube through the pylorus using laparoscopy .

• 7.

  Percutaneous transesophageal gastrostomy (PTEG). This technique was first described in 1998 and has not been FDA approved. Placement utilizes ultrasound and fluoroscopic detection of a balloon inflated in the cervical esophagus. A needle is used to access the balloon percutaneously from the neck. The wire and balloon are then advanced into the stomach. Following retraction of the balloon, a feeding catheter is placed percutaneously through the neck into the esophagus and then advanced into the stomach .

Commentary : The indication for this approach is limited to patients who are constantly trying to remove their abdominally-located feeding tube because of psychiatric reasons or in settings of dementia.

Complications of gastrostomy and PEG are low, varying between 5 to 25% and are most commonly attributed to infection. Other complications include tube dislodgment (12.8%), bleeding (1%), aspiration pneumonia, and visceral perforation, the latter mainly determined by the experience of the physician/operator .

Commentary, important advice, and words of caution : Gastrostomy is not a long-term recommendation. If patients cannot tolerate liquid or minimal solid food intake and they actually vomit/regurgitate within 5–20 minutes after intake, then the diagnosis is rumination syndrome and not gastroparesis, and the treatment for rumination syndrome is not gastrostomy. Also the “eating disorder” – anorexia/bulimia is another possibility that can present as immediate post-prandial vomiting, regurgitation, and it is not treated by a gastrostomy. Hence while popular in the pediatric setting, gastrostomy tubes have a very limited, if any, role in managing adults with gastroparesis – unless for a temporary use while resolving a pyloric or small bowel obstruction. In addition, the use of a gastrostomy suction eliminates the stomach from experiencing distention and preparing for the obvious future – oral intake. This tube approach delays and procrastinates appropriate treatment decisions as well as “hiding the diagnosis” by minimizing attempts at instituting oral nutrition intake.