Endoscopic and Surgical Treatments for Gastroparesis: What to Do and Whom to Treat?

Abstract

Gastroparesis is a complex chronic debilitating condition of gastric motility resulting in the delayed gastric emptying and multiple severe symptoms, which may lead to malnutrition and dehydration. Initial management of patients with gastroparesis focuses on the diet, lifestyle modification and medical therapy. Various endoscopic and surgical interventions are reserved for refractory cases of gastroparesis, not responding to conservative therapy. Pyloric interventions, enteral access tubes, gastric electrical stimulator and gastrectomy have been described in the care of patients with gastroparesis. In this article, the authors review current management, indications, and contraindications to these procedures.

Keywords: Gastric electrical stimulator; Gastric pacemaker; Gastric peroral endoscopic myotomy (GPOEM); Gastroparesis; Peroral pyloromyotomy (POP); Pyloromyotomy; Pyloroplasty.

Figures 1

Steps of the GPOEM procedure. A. Initial mucosal entry – 5 cm proximal to the pylorus on the greater curvature. B. Dissection of the submucosal entry. C. Myotomy. D. Closure of the mucosotomy with the Overstitch device.

Figure 2

Surgical pyloroplasty procedure. A. Placement of the incisions across the pylorus. B. Approximation of the defect in the transverse fashion. C. Heineke Mikulicz closure of the pyloroplasty incision. D. Reinforcement of the closure with omental flap.

Figure 3

Gastric electric stimulator implantation procedure. A. Placement of the stimulator in the subcutaneous pocket in the left subcostal area. B. Intramural placement of the electrodes with direct visual control with intraoperative endoscopy.

Figure 4

Complication of jejunostomy tubes. A. Early postoperative migration of the balloon into the abdominal wall with the leak and necrotizing fasciitis of the abdominal wall. B. Late postoperative erosion of the balloon through the abdominal wall resulting in the leak and dermatitis.

Figure 5

Different location of the device in the abdominal wall. A. Right lower quadrant location with long intraabdominal course of the leads. B. Left subcostal area location with very short intraabdominal length of the wires with the majority coiled over the fascia under the device. From Frontline Medical Communications Inc., publisher of the Journal of Clinical Outcomes Management; 2019; 26(1):31-32; with permission.

Figure 6

Complications of the gastric electric stimulator. A. Erosion of the device through the skin. B. Postoperative hematoma. C. Specimen of resected segment of the gastric wall due to erosion of the GES leads component (please note silicone retention disk protruding though the mucosa). From Frontline Medical Communications Inc., publisher of the Journal of Clinical Outcomes Management; 2019; 26(1):31-32; with permission.

Figure 7

Twiddler syndrome. A. Postoperative image after implantation of the GES. B. Image of the same patient 11 month postoperatively. Patient returned with recurrence of symptoms and image reveals flipped device with braded leads.

Figure 8

TYRX Antibiotic envelope for the cardiac stimulator.

Figure 9

Bowel obstruction due to stimulator leads. A. Preoperative scout image revealing high grade bowel obstruction and stimulator leads. B. Intraoperative image of the same patient, demonstrating loops of bowels wrapped around the leads. Leads were preserved. C. Postoperative image of another patient after laparotomy for bowel obstruction where leads were sacrificed. From Frontline Medical Communications Inc., publisher of the Journal of Clinical Outcomes Management; 2019; 26(1):31-32; with permission.

Figure 10

Placement of gastric stimulator leads. A. Fixation of the leads in the muscular layer of the gastric wall. B. Omental flap coverage of the implanted leads.

Figure 11

Abdominal imaging in the investigation of patients with recurrence of symptoms and abnormal Impedance values. A. Fracture of the lead along the medial border of the device. B. Migration of the lead. Please note wide spaced distance between the leads and lack of association of the medial lead with retention clips. From Frontline Medical Communications Inc., publisher of the Journal of Clinical Outcomes Management; 2019; 26(1):31-32; with permission.

Figure 12

Decision algorithm for the choice of procedure in patients with gastroparesis.