Juan P. Toro

Efficacy of Laparoscopic Pyloroplasty for the Treatment of Gastroparesis

BACKGROUND The modest results of nonoperative modalities for the treatment of gastroparesis necessitate greater consideration of surgical therapies. However, the role of surgery is not well defined. The aim of this study is to present our experience with laparoscopic pyloroplasty as early treatment for gastroparesis. STUDY DESIGN Fifty patients with refractory gastroparesis underwent laparoscopic pyloroplasty (hand-sewn Heineke-Mikulicz configuration) from 2006 to 2013 at our institution. Preoperative and postoperative symptom data, gastric emptying scintigraphy, and technical outcomes of the procedure were reviewed. A single-factor ANOVA was performed for the comparison of continuous variables. Results are reported as mean ± SD or median absolute deviation. RESULTS Thirty-four of 50 (68%) patients had previous foregut procedures and/or cholecystectomy. Thirty-two of 50 (64%) patients underwent concomitant procedures (ie, paraesophageal hernia repair and gastrostomy takedown) along with the pyloroplasty. Operative time, including combined procedures, blood loss, and length of stay were 175 ± 56 minutes, 64 ± 50 mL, 2.5 ± 2.7 days, respectively. There were no conversions to open technique or intraoperative complications. There were no suture-line leaks. The readmission rate was 14%. All patients had symptom follow-up and 33 (66%) had postoperative gastric emptying scintigraphy. Postoperative symptom improvement was reported by 82% of the patients (p < 0.001). Median preoperative T1/2 was 180 ± 73 minutes and postoperative T1/2 was 60 ± 23 minutes (p < 0.001). Five patients (10%), who had normalized postoperative T1/2 times, required other gastric emptying procedures; distal gastrectomy (n = 2), duodenojejunostomy (n = 2), and gastric stimulator placement (n = 1). CONCLUSIONS Laparoscopic pyloroplasty is an effective early-treatment modality for selected cases of gastroparesis, with substantial improvement in objective gastric emptying times and low morbidity. The laparoscopic approach does not preclude subsequent procedures when necessary.

Observed Variability in Sleeve Gastrectomy Volume and Compliance Does Not Correlate to Postoperative Outcomes.

Background: Restrictive bariatric procedures reduce gastric capacity as a primary mechanism of action. Intraoperatively, surgeons observe variability in size and compliance of specimens. We hypothesized that higher gastric specimen volume or tissue compliance would respond better to restrictive procedures. Materials and Methods: Consecutive patients undergoing laparoscopic sleeve gastrectomy between September 2012 and September 2013 were enrolled. Specimens were insufflated at graduated pressure points creating pressure volume curves, and compliance was calculated. Postoperative weight loss and a hunger scores were recorded. Correlations were determined by Spearman correlation. Results: Eighty-four patients consented to enrollment. Mean age, weight, and body mass index (BMI) were 45±12 years, 126±23 kg, and 45.4±6 m/kg2, respectively. The resected specimens varied in insufflated capacity from 0.3 to 1.8 (0.71±0.32) L and compliance varied from 14.3 to 85.7 (36.1±14.7) cc/mm Hg. Male patients had a larger greater curvature length (GCL) (P<0.001), staple line length (SLL) (P=0.03), gastric volume (GV) (P=0.002), and gastric compliance (GC) (P<0.001). Neither GV nor GC correlated to excess body weight loss (EBWL%) as hypothesized. There was an inverse correlation between hunger score and GV (P=0.010). The mean 1-month, 3-month, 6-month, and 12-month EBWL was 17.4%, 33.2%, 43.7%, and 54.1%, respectively. Follow-up was 71.4% at 1 month, 39.3% at 3 months, 54.8% at 6 months, and 42.9% at 12 months. Conclusions: Sleeve gastrectomy specimens exhibit nearly 6-fold variability in both volume and compliance. A large GC is anticipated in male and tall subjects. These observations do not appear to be correlated to %EBWL.