Keneth Hall, MD, FACS, FASMBS, Raelina S Howell, MD, Harika Boinpally, MD, Patricia Cherasard, PAC, Patrizio Petrone, MD, Collin E Brathwaite, MD, FACS, FASMBS. NYU Winthrop Hospital
Introduction: Patients with morbid obesity and gastroparesis can be treated with sleeve gastrectomy (SG), which has been shown to increase gastric emptying, decrease transit time, and increase glucagon-like peptide levels. Historically, in the setting of refractory gastroparesis following SG, conversion to Roux-en-Y gastric bypass (RNY) was used as a salvage procedure. However, there are limited surgical options for patients with refractory gastroparesis who are poor RNY candidates (ie high risk for anastomotic breakdown such as in Crohn’s disease, high-dose steroids, immunosuppressed) or who are unwilling to undergo RNY. This case series describes the unique surgical management technique of rescue pyloroplasty with sleeve gastrectomy (SG) for patients with morbid obesity (body mass index [BMI] ≥35 kg/m2) and refractory gastroparesis.
Methods: A retrospective chart review was performed for patients with morbid obesity and gastroparesis who underwent SG and simultaneous or subsequent pyloroplasty by a single surgeon at a Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Center of Excellence from August 2016 through July 2018. Patient workup, surgical techniques, and outcomes were assessed.
Results: Three patients underwent SG and simultaneous pyloroplasty (n=2) or subsequent pyloroplasty (n=1) and were included in this case series. The first patient was a 70-year-old female with a BMI of 36 who had undergone placement and removal of two prior adjustable gastric bands. She underwent laparoscopic SG, but complained of bloating and dysphagia during postoperative visits and was found to have gastroparesis on a gastric emptying study. She then underwent robotic revision SG and pyloroplasty with subsequent symptom resolution. The second patient was a 46-year-old male with diabetic gastroparesis (hemoglobin A1c 6.8) and a BMI of 40 who was offered RNY, but elected for SG with pyloroplasty and also had postoperative resolution of symptoms. The third case was a 34-year-old female with a BMI 37.8 and idiopathic, refractory gastroparesis who underwent laparoscopic SG and pyloroplasty. She was readmitted on postoperative day seven for liquid intolerance that resolved with conservative, non-operative management and she was discharged home the same day with continued symptom resolution during subsequent follow-up.
Conclusion: We have demonstrated good results with the use of rescue pyloroplasty following SG in patients with morbid obesity and refractory gastroparesis. In patients with gastroparesis who have already undergone sleeve gastrectomy, surgeons should consider pyloroplasty as a salvage maneuver prior to conversion to RNY, keeping in mind that conversion is still an option if symptoms persist.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 95335
Program Number: P045
Presentation Session: Poster Session (Non CME)
Presentation Type: Poster