Introduction: Nausea and vomiting following Roux-en-Y gastric bypass is a common complaint that can have multiple etiologies, frequently related to anatomic problems or disordered eating behavior. Gastroparesis can occasionally be responsible for these symptoms in some patients and can be difficult to treat.
Material and Methods: We reviewed the charts of six patients who presented with refractory gastroparesis following a prior Roux-en-Y gastric bypass. Two patients had a concomitant truncal vagotomy at the time of their surgery. They were all women with mean age of 42 years. The symptoms included nausea, vomiting, bloating/distension, early satiety, and abdominal pain, with a mean total symptom score of 15 (out of 20). The onset of symptoms varied from immediately postoperatively to 16 years following the surgery. All patients did not respond to various promotility agents. Two patients ultimately had reversal of their surgery with gastro-gastrostomy, while another had a total gastrectomy, with persistence of the symptoms in all three of them.
Results: All patients had markedly abnormal radionucleotide gastric emptying with 4/6 patients showing slow gastric emptying (mean gastric retention of 78% at 4 hours) and 2/6 patients with rapid gastric emptying (mean gastric retention of 27% at 1 hour). Temporary endoscopic pacing was performed on all patients with improvement in their total symptom scores to a mean of 8 (out of 20) and improvement of their gastric emptying (delayed group improved to 35% at 4 hour and rapid group improved to 30% at 1 hour). Four of the patients evaluated had insertion of a permanent gastric pacemaker, with implantation of the pacing leads on the gastric pouch (2 patients) or proximal Roux limb (2 patients). Symptoms improved significantly postoperatively with mean nausea score of 1.5/4, mean emesis score of 2.2/4 and mean total symptom score of 10.5/20. There was also a persistent improvement in gastric emptying postoperatively based on radionucleotide testing (delayed group improved to 28% at 4 hour and rapid group improved to 57% at 1 hour).
Conclusion: Gastroparesis is a rare complication of Roux-en-Y gastric bypass, especially in the setting of concomitant vagotomy, and should be considered when no anatomic or behavioral problems are identified. If medical therapy fails, electrical stimulation is a good option in selected patients and should be considered in lieu of reversal surgery or total gastrectomy.