A gastroenterologist’s view of post-surgical complications and

gastroparesis

George Triadafilopoulos, MDClinical Professor of Medicine

Stanford University School of Medicine

MISS, Salt Lake, UT, 2.22.2011

Outline

• What can happen

• How do we find out

• What can we do about it

What can happen…

Reasons for revisional surgery

%

N=109 pts

Lamb et al. Br J Surg. 2009;96(4):391-7

Esophagus – Diagnostic Steps

Barium studies

Intra-thoracic wrap migration

Revisional surgery

Endoscopy: Intact fundoplication

Multichannel intraluminal impedance assesses esophageal

clearance

Recurrent, persistent, or new onset of dysphagia after

antireflux surgery

3 possibilities:

• Patients with signs of obstruction at or above the GEJ suspicious of “crural stenosis” (40%).

• Patients with signs of total or partial migration of the wrap intra-thoracically (50%).

• Patients in whom the hiatal closure is radiologically assessed to be correct with a supposed “stenosis of the wrap” (10%).

Pneumatic dilation for crural stenosis: 85% successful

Stomach/Intestine – Diagnostic Steps

Gastric emptying study in gastroparesis

Nissen vs Toupet fundoplication

Gas-bloat symptoms post NissenDigestive and Liver Disease 39 (2007) 312–318

Gas-bloat symptoms post ToupetDigestive and Liver Disease 39 (2007) 312–318

Bloating before and after fundoplication +/- pyloroplasty

World J Surg. 2007;31(2):332-6

*

Concomitant pyloroplasty improves gastric emptying in GERD patients

with gastroparesisWorld J Surg. 2007;31(2):332-6

Medical therapy of mild to moderate gastroparesis

• Dietary modification• Liquid supplements• Metoclopramide• Domperidone• Erythromycin• Antiemetics• PPI

Camilleri, M. N Engl J Med 2007; 356:820

Medical therapy of severe gastroparesis

• Pyloric BoTox injection• Enterra• Venting PEG & feeding PEJ• Subtotal gastrectomy & Roux-en-Y gastro-

jejunostomy

Camilleri, M. N Engl J Med 2007; 356:820

Pyloric motility and BoTox injection for gastroparesis

Pyloric BoTox for gastroparesis

% improvement at 2 months, n=6

Ezzedine et al. GIE. 2002;55:920-3

Enterra® for refractory post-

surgical gastroparesis% improvement at 60 months n=31

McCallum et al .CGH 2011

Small bowel bacterial overgrowth

• Diagnosed by lactulose breath test (early rise in hydrogen production)

• Treatment with antibiotics– Rifaximin– Augmentin plus metronidazole– Septra plus metronidazole– Norfloxacin

Conclusions

• Post-fundoplication syndromes are multifaceted and require thorough evaluation

• Revisional surgery may be needed

• Medical therapy for gas bloat and gastroparesis is complex and suboptimal