Sleeve Gastrectomy for Gastroparesis

Novel use of weight loss surgery may help patients debilitated by gastroparesis.

Sleeve gastrectomy
Courtesy of Ethicon Endo-Surgery, Inc
Sleeve gastrectomy, also called vertical sleeve gastrectomy or gastric sleeve, has been long used as the first stage of weight loss surgery in patients with very high body mass index (BMI). In this laparoscopic procedure, the size of the stomach is reduced to about 15% of its size. Over many years, physicians observed that patients lost weight very effectively after sleeve gastrectomy without undergoing biliopancreatic diversion, the second and more invasive stage. As a result, bariatric surgeons frequently perform sleeve gastrectomy as a standalone procedure today.

As advanced as modern medicine has become, in some cases, it still falls short. Patients who develop a condition called gastroparesis are among those who may exhaust the limits of available therapies. It is for patients such as these that physicians at NewYork-Presbyterian/Columbia have once again stepped up and found new avenues of treatment – and hope.

Gastroparesis is a disorder in which the stomach cannot contract and empty its contents into the intestines. Because patients with gastroparesis cannot move food properly through their digestive system, they may experience symptoms including pain, nausea, vomiting, abdominal bloating, malnutrition, and more. Although a number of conditions may cause gastroparesis, by far the most common is diabetes, in which continued high blood sugar levels damage the vagus nerve, which controls the movement of food through the digestive tract. Gastroparesis can develop as a consequence of either type 1 or type 2 diabetes that is poorly controlled.

Conventional treatments may include medical therapies, dietary changes, and implantation of a gastric electrical stimulator, or 'gastric pacemaker,' an implanted device that helps to control nausea and vomiting. If all of these fail to help, however, patients may have no choice but to receive nutrients through feeding tubes – not an attractive option for anyone, but especially younger patients. According to Melissa Bagloo, MD, Assistant Professor of Clinical Surgery, Division of Minimal Access/Bariatric Surgery, "There are many patients who do not improve with current treatments and whose quality of life continues to deteriorate. This is a debilitating condition that can be very frustrating for both patients and physicians."

At the Center for Metabolic and Weight Loss Surgery, NewYork-Presbyterian Hospital/Columbia University Medical Center, Dr. Bagloo and colleagues are now testing a procedure that has shown excellent initial results in this difficult-to-treat population. Based on their long-term experience, Marc Bessler, MD, Director, Center for Metabolic and Weight Loss Surgery, and colleagues believed that a laparoscopic procedure called sleeve gastrectomy just might help patients with severe gastroparesis. When four patients with gastroparesis were unable to receive gastric pacemakers early this year, the surgeons performed sleeve gastrectomy, normally used to help patients lose weight, to see if it might help.

According to Dr. Bagloo, "We had previously observed that after sleeve gastrectomy, patients who had difficulty emptying their stomachs showed significant improvement in their digestion. We do not know precisely why this is: Sleeve gastrectomy may have the effect of 'resetting' the natural gastric pacemaker, or it may be that the smaller size of the stomach increases intragastric pressure so that it helps facilitate gastric emptying. There could also be other reasons why the surgery helps."

The four patients who underwent sleeve gastrectomy at the center in 2010 were all diabetics with severe gastroparesis. For various reasons, they were not eligible to receive a gastric pacemaker. After surgery, two of the patients did very well right away, and the other two needed nutritional support for several months. "At six months after surgery, all four were eating, drinking, and were no longer experiencing nausea or vomiting. For patients who faced the prospect of lifelong feeding tubes, the benefits of such a successful outcome cannot be overstated," says Dr. Bagloo.

The risks associated with laparoscopic sleeve gastrectomy are minimal, and include leakage in the staple line (2-3%), wound infection, and post-operative pain. Unlike implantation of a gastric pacemaker, sleeve gastrectomy leaves no foreign object, which can erode, get infected, or require subsequent procedures to replace batteries, in the body. Although other surgeries have been attempted in patients with gastroparesis, they are larger operations with significant risks, says Dr. Bagloo. "We believe that laparoscopic sleeve gastrectomy may be a less invasive option that allows patients to eat normally and regain their quality of life."

No other group has reported using sleeve gastrectomy to treat gastroparesis. Based on the success in the initial four patients, NYP/Columbia is conducting further study. The Center for Metabolic and Weight Loss Surgery is concurrently developing a program that will offer all treatments, including gastric pacemakers and sleeve gastrectomy, for patients with gastroparesis.

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