Surgical Treatments for Gastroparesis –  Parham Doctors’ Hospital

Surgical Treatments for Gastroparesis – Parham Doctors’ Hospital


– So now we’re gonna talk
about surgical therapies. Full disclosure, I’m a surgeon, so I know probably more about
this than anything else although I do plenty of other therapies. I treat lots of people, though, I don’t think just because you have a gastroparesis you need surgery and most people don’t. We’ve already talked about diets and medications and lots of people are gonna be better, or even waiting and doing nothing. Some people will come to surgery. It’s a smaller percentage. And we’re gonna go in the order of history rather than frequency just
to give you a better sense of how things have evolved over time. The first surgical therapy
we’re gonna talk about is gastric electrical stimulation. This is probably better known
as the gastric pacemaker. The trade name is Enterra. E-N-T-E-R-R-A. It’s a device. It was introduced and approved
in this country around 2001. I was in one of the
initial training classes from Medtronic, the company that makes it. And it’s a modified pacemaker. And initially what was thought was we were gonna take
a modified pacemaker and take some wires, just like we take wires from a pacemaker and put them in the heart, put ’em on the stomach,
turn this thing on, and then the stomach is gonna
start pumping the food out. And what we know for sure is
it doesn’t work like that. That this is truly neural stimulation. It comes back to sort
of what’s the problem in gastroparesis, or in
some forms of gastroparesis. And the problem is, is
the nerves are damaged. And so what do the
nerves do in the stomach? Well, autonomic nerves, or
nerves that go to the intestine, are not like our skeletal muscle nerves. Our skeletal muscle nerves, the ones that move our arms and our hands, when the nerve fires, the electrical impulse
causes the muscle to contract and it’s the exact
opposite in the intestine. When the nerves fire, it
causes the muscle to relax. And so you can imagine
that in the stomach, if the nerves are injured, then the muscle is not
relaxing at the right time. And maybe it even spasms
when the patient eats. And that’s why we sometimes
see patients who smell food and all of a sudden become very
nauseated and have retching, or they eat like one bite and all of a sudden they’re
vomiting like crazy. It’s not like they had a giant
meal and they’re vomiting. It can be literally one bite. And so this denervation
effect can be very prominent and the stimulator renervates. It gives electrical
stimulation to the stomach. And there certainly is
a sub-group of people who think that it
increases at combination. That is, it helps the stomach relax when the food comes down. This is borne out by some
of the evidence in which, you know, the majority of patients who have a stimulator, their
stomach doesn’t empty better if we measure gastric emptying before and we measure gastric emptying after. It’s actually the same. There’s a minority that
will have improved emptying, but the majority do not. And yet the vast majority of
people who get a stimulator, 75%, will experience
significant improvement in their symptoms and so
we think about the problem as denervation, then gastric stimulation seems to make a lot more sense. Like I said about 75% of
people are gonna improve. This therapy is much more
effective in diabetics than it is in idiopathic patients. My experience is about 80% of diabetics are gonna have improvement and about 50% of folks who
are idiopathic gastroparetics are gonna have an improvement. Not that it can’t work,
but it’s not as effective. And so for gastric stimulation, that’s my first line
therapy for the patient who has a diabetic gastroparesis. Especially the ones that
sort of have symptoms that sound like denervation gastric spasm. And so those people,
generally, would do pretty well with a gastric stimulator. And so we’ll offer that
as first line therapy, and then we’ll progress through therapies if they need something else. Now the gastric stimulator
is a device, right? So it’s a battery pack and it’s wires that go through the abdominal
wall into the stomach. The battery has a lifetime
just like any battery, the battery in your
car or your cell phone. That battery has to be replaced,
depending on the settings, between five and eight
years after it’s placed. So you talk about putting
a gastric stimulator in a patient who’s 40 years old, they’re potentially looking at multiple replacements of the device. It’s one of the reasons now we will commonly
use adjunctive therapy, or adjunctive surgery,
with the stimulator. And we’ll talk about
pyloroplasty in a minute. So most people will now do a pyloroplasty at the same time as a stimulator trying to get as much effect as possible, and maybe decreasing the frequency with which the stimulator
needs to be changed. The very few complications
with the stimulator. Your provider can give you
a lot more detail on this, but it’s generally a safe operation done with a video laparoscope. I keep people overnight, but some people send them home
the same day and that’s fine. The next therapy we’re gonna talk about is laparoscopic pyloroplasty and this is a relatively new procedure. There’s another, if you go to our site, there’s another little
slideshow you can read through that has a lot more
information on pyloroplasty with some references, and I encourage that if you wanted to learn more. This is a procedure that’s been around for about three years now, commonly. Maybe a little bit longer. And based on some information out of the University of Oregon
was really the first group to publish on this, where they just took a bunch of people who had gastroparesis and laparoscopically, they cut the muscle at the end of the stomach. Now, if you think about the
Botox data a little bit, you would think that it probably wouldn’t work that frequently, if Botox is working great
20% of people respond, then we should expect 20% of people who have the muscle
physically cut with surgery should also respond. And I think everybody in
the group of people I know are really impressed that it works much more frequently than that. The published data is like
75-80% improvement in symptoms and improvement in gastric emptying. So remember, with the stimulator, there was no improvement
in gastric emptying. With pyloroplasty, improvement
in gastric emptying as well. And so for those folks
who have like bad reflux, from retained gastric secretions, this is like a better procedure for them. And so I started doing this
procedure several years ago. I use it routinely in the idiopathics, ’cause those people seem to do better. There’s been additional information over the last couple years on looking at pyloris and pyloric function in patients with idiopathic gastroparesis, and turns out, not surprisingly, that the muscles in the patients who have idiopathic gastroparesis tend to be higher pressure. They’re squeezing harder
and they’re hypertrophic. They’re thicker than
they’re supposed to be and this may be part of the ideology, or the cause of the
ideopathic gastroparesis. So you eliminate that,
you cut that muscle, that spasm or that high
pressure is eliminated and patients feel much better. So my experience has been similar to that of the medical literature. Many, many people improved
quite dramatically. It’s a laparoscopic operation, it’s an overnight
hospital stay in my hands. It’s cutting the intestine, so
there’s a little bit of risk: bleeding, infections,
rare incidents of leakage, but it’s no implant. So there’s no adjustments afterwards, there’s no batteries to be changed, and so it has that benefit. So it’s a nice little procedure. It works really well for people. There’s few side effects,
and so we like doing this. And again, I think the
consensus opinion now, is that for even diabetics who
are gonna have a stimulator, we add pyloroplasty to that
to get the added benefit of increased emptying and see that result. Those two therapies work great together. You can do them sequenced,
you can do them together, and they seem to really
improve people’s life and get them back onto
eating normal foods. Again, the destination
for all these therapies is eating normal foods. Now, does that mean
chicken wings every night? Doesn’t mean chicken wings every night. It means maybe chicken wings. What it does mean is
you can eat solid food with your family and not be ostracized to some sort of minuscule
diet or boring liquid diets or things that really take away from the quality of life, right? I mean, we live so much of
our life around the table. So many of our meaningful events in life are around eating that, you know which our obligation
to try to help people get to a point where
they can eat normally. And so these procedures
really provide that and so it’s really,
these are good therapies. Now not every single
person is gonna get better with those two therapies. And in my experience it’s
really the very severe diabetics who don’t have a hypertensive
stomach any longer. They have a completely flaccid stomach. There’s no emptying at all. We’ll sometimes see on the
gastric emptying setting, what’s called an ascending curve. They don’t see it empty at all over the course of four hours. Sometimes even cutting the muscle or putting a stimulator’s
not gonna help those people and they can benefit from
having their stomach removed. The stomach is removed, you know an operation that looks similar to a gastric bypass, where we create a very small pouch at
the top of the stomach, bring intestine up. So if you look at the diagrams
that you see on your screen, the food is coming down the
food tube into the small pouch and directly into the intestine. Doesn’t ever enter the stomach, and that stomach is then removed so that it can’t cause any of
the symptoms the patient has. This has also been studied pretty, more aggressively now that we’re seeing more patients for gastroparesis therapy. And it can work very well. Is this the first line
therapy for most people? I don’t think so. I think most people are
gonna get better without it. This is really a therapy as an end stage. Highly effective but there’s
some management involved. Those patients who require this therapy will behave very similar to
weight loss surgery patients and generally speaking,
somebody who gets this therapy, they don’t need to lose weight. That’s not the problem. The problem is that they
can’t keep their weight on and so we have to work pretty
intensely with those folks. They’re diabetic, so they’re
gonna see a dramatic alteration in their insulin metabolism,
they’re not gonna be hungry, so we really gotta help them. If the patient has a
jejunostomy tube already we’ll keep it to help them
through the adjustment period. But people are getting admitted
every month to the hospital for severe symptoms. We can make that better and
this is a good therapy for that in the right patient. And so it’s a big therapy, though, and I don’t think the patient comes to the office the first time
and we sit down and say, “Hey, you need to have your stomach out.” Right? It’s a process. It’s getting to know one another, understanding what the disease
is, trying some therapies. If it gets to that, it’s great, and it works, works
well, but in my opinion, not a first line therapy. So a final therapy that’s surgical that we offer for gastroparesis
is actually gastric bypass, which you are probably more familiar with in terms of weight loss. Paradoxically, we will see some patients with very severe gastroparesis. Lots of nausea and vomiting, who are significantly overweight and while sometimes
people can’t understand how that can happen,
remember, gastroparetics, when they’re able to eat foods, it’s typically high calorie
liquids and low fiber foods. Those tend to have a lot of added sugar lots of carbohydrates, and for some people’s metabolism, that will lead to obesity
very, very quickly and so we’ll see a
sub-population who are obese or morbidly obese with a
body mass index over 35, who need therapy for gastroparesis. And in that group, we’ll
offer them gastric bypass and that’s, you can see on your
screen the picture of that. It looks very similar to
the subtotal gastrectomy, except that we leave the stomach part in. This is well studied, it works very well, it leads to weight loss which is much healthier for the patient. For the diabetics, it frequently leads to remission of their diabetes, their high blood pressure,
their sleep apnea, and a resolution to the
nausea, so that, again, they’re able to eat more normal foods. Healthier, high quality foods. Higher in protein, some raw vegetables. And so we use that therapy in this group and it seems to work well. It’s a minority population, but it’s still important to mention. (upbeat instrumental music)

2 thoughts on “Surgical Treatments for Gastroparesis – Parham Doctors’ Hospital

  1. i had a pyloroplasty in july of 2016 and it worked for about 6 months but i also have alot of other gi issues like achalachia is there anything else i can do cause right now i can't eat r drink anything and i'm on a gj tube and my gi said that i am getting very acidic and said about puting a j tube in is there anything else i can try i went to be able to eat i'm only 39 please any ideas would be great ty

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