Advances in Gastroparesis

Dmitry Oleynikov M.D, F.A.C.SAssociate Professor of Surgery

Joseph and Richard Still Faculty Fellow in MedicineDirector of Minimally Invasive And

Robotic Surgery

University Of Nebraska School Of Medicine

Gastric Emptying Physiology

1. Fundus/body relaxation

2. Antral tirturation

3. Fluctuations in pyloric tone

4. Antro-pyloro-duodenal coordination

5. Sensory inputs

a. CNS

b. From the stomach (gastrin, secretin)

c. From the small intestine

Definition

The diagnosis of Gastroparesis is based on the presence of appropriate symptoms/signs, delayed gastric emptying, and the absence of an obstructing structural lesion in the stomach or small intestine.

Causes• Idiopathic 39%

– Functional dyspepsia (FD)– GERD– Post Viral syndrome

• Diabetes Type I and II 29%• Post gastric surgery 13%

– Vertical Banded Gastroplasty– Partial gastrectomy

• Parkinson’s Disease 4.8%• Chronic Idiopathic intestinal Pseudoobstruction

4.1% Soykan et al. DDS 1998

Evaluation• Gastric emptying scintigraphy

– Minimum 2 hours but greater than 4 can be more accurate

• Breath testing – nonradioactive isotope 13C to label octanoate, a

medium-chain triglyceride• Antroduodenal manometry

– Decreased antral contractility and originating fast Migrating motor complex (MMC) in small intestines

Treatment

• Primary treatment includes dietary modification and antiemetics and prokinectic agents

• Dietary modifications– Low fat diet– Frequent small meals – Replacing solids with liquid calories i.e. soup

and protein shakes

Treatment

• Prokinetic agents– Metoclopramide and erythromycin are most

common agents– Cisapride although associated with cardiac

arrhythmias not available in US– Muscarinic cholinergic agents (bethanechol),– Anticholinesterases (pyridostigimine)– Serotonin agonist (i.e. tegaserod )

Treatment

• Antiemetics – Antiemetic agents are are administered for

nausea and vomiting. – antidopaminergics, antihistamines,

anticholinergics, and serotonin receptor antagonists

– phenothiazine compounds i.e. prochlorperazine, trimethobenzamide, and promethazine at a

Treatment

• Prokinetic agents– Erythromycin– Metoclopramide– Cisapride

Refractory to medications

• Botulism toxin injection into pylorus• Gastric electrical stimulation or pacing• Surgery treating symptoms i.e. gastrostomy tube

placement or nutritional support i.e. jejunostomy tube placement

• Gastric resection i.e. subtotal or total gastrectomy for severe intractable gastroparesis

Endoscopic Injection of Botox

• Small case series show improvement in emptying after injection of botulism toxin

• Clinical studies fail to show any benefit to this procedure .

Arts J, et. al Aliment Pharmacol Ther. 2007;26(9):1251-8.

Gastric Electrical Stimulation (GES)

• The device (Enterra, Medtronic) approved by the FDA through a

humanitarian device exemption• GES involves the use of electrodes, usually placed laparoscopically

into musculature of antrum• Unclear how the stimulation works• May control symptoms but not cure disease state• RCT w/ 33 pts with idiopathic or diabetic gastroparesis, electrical

stimulation no effect on symptoms overall but reduced the weekly

frequency of vomiting (p<0.05).

Abell T et al. Gastric electrical stimulation for medically refractory gastroparesis

Gastroenterology. 2003;125(2):421-8.

Gastrectomy for Gastroparesis

• Total or subtotal gastrectomy may relieve symptoms of nausea and vomiting

• Roux-en-y reconstruction preferred to limit bile reflux

• 6 out of 7 patients had complete resolution of symptoms as well as follow up to 6 years

Watkins et al. Long-term outcome after gastrectomy or intractable diabetic gastroparesis. Diabetic Medicine, 20: 58–63.

Morbid Obesity and Gastroparesis

• In our unpublished series of 6 pts with morbid obesity and gastroparesis, pts symptoms improved with laparoscopic vertical sleeve gastrectomy and had significant weight loss

• 4 of 6 pts had severe symptoms and completely resolved.

• Will repeat gastric emptying study once patients are over one year

Conclusion• Gastroparesis is a difficult condition to manage.• Medical therapy still remains the mainstay

treatment• New technologies still show no significant

advantage over medical treatment• Laparoscopic Vertical Sleeve Gastrectomy may

provide benefit to morbid obese and diabetic pts with gastroparesis