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SURGICAL MANAGEMENT OF GASTROPARESIS: AN ALGORITHMIC APPROACH
Pavani Peddi
*, Ryan Shargo, Isaac Poonen-Honig, Chamanthi Konidala, Cameron Dabbs, Rebecca Klam, Bailey Blankenship, Adham Saad, Salvatore Docimo Jr., Christopher DuCoin, Camille Thélin, Joseph Sujka
GI Surgery, University of South Florida, Tampa, FL
Gastroparesis is a chronic dysmotility disorder characterized by delayed gastric emptying in the absence of mechanical obstruction. Subtypes of gastroparesis include idiopathic, diabetic, postsurgical, and postinfectious with idiopathic gastroparesis being the most common.
Management involves a multidisciplinary approach involving specialists in gastroenterology, GI surgery, nutrition, and psychiatry. Recently published American Gastroenterological Association guidelines outline recommendations for medical management but provide limited guidance for surgical intervention. Thus, the goal of our study was to develop an algorithm to assist practicing surgeons in the management of gastroparesis.
Patients are typically referred to a surgeon after failing lifestyle modifications and medical management of symptoms. Upon evaluation, surgeons may determine which, if any, tests should be repeated. Common diagnostic tests for gastroparesis include gastric emptying studies, upper gastrointestinal series, or upper endoscopy. Our current practice is to repeat upper endoscopy with pyloric dilation to assess the need for pyloric intervention. We proceed with pyloroplasty if there is significant improvement to patient symptoms and avoid it if symptoms worsen. In equivocal cases, we proceed with botulinum toxin injection along with pyloric dilation. If symptoms persist, we discuss additional options such as gastric electrical stimulation, pylorus directed therapies (gastric peroral endoscopic myotomy or pyloroplasty), or a combined approach. In refractory cases, gastric bypass is considered.
Overall, we aim to provide a surgical algorithm for the management of gastroparesis refractory to medication and lifestyle modification. Ongoing research is needed to further define optimal disease management.
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