Completion gastrectomy for refractory gastroparesis following surgery for peptic ulcer disease

Abstract

We recently have shown that 50% of patients with preoperative gastric outlet obstruction go on to develop chronic nonmechanical gastric stasis after surgery and require further operations in attempts to relieve their symptoms. In the present study we report our experience with completion gastrectomy (CG), offered to a subgroup of this population who failed to respond to both available and experimental medical therapy with prokinetic agents. Manometric studies of the small bowel were performed on three of these patients using a semiconductor solid recording probe to assess the motility of efferent jejunal limbs. There were seven females and one male (N=8) with a mean age of 45 years. All had persistent symptoms of abdominal pain, bloating, nausea, vomiting, early satiety, decreased appetite, and weight loss dating back to the time of surgery. Gastric stasis was documented by delayed gastric emptying of a radionuclide solid meal (chicken liver labeled with technetium-99m sulfur colloid) with a mean retention of 86±6.2% (<60% being normal) in the setting of an upper endoscopy showing stomal patency. The mean duration of symptoms was 31.6±15.7 months (range 6–60) since the last surgery. The number of previous gastric opertions was a mean of 2.3 per patient. Five of eight patients had undergone a Roux-en-Y procedure as the last operation while the other three had a Billroth II. Surgery consisted of a 90% or complete resection of the remaining stomach and a jejunal-esophageal anastomosis. In some cases the Roux-en-Y limb was lengthened to >45 cm if needed. The mean duration of follow-up after CG is 30±20.8 months (range 7–60). No patient has required any additional operations or promotility agents. Based on global evaluation, all patients reported a satisfactory quality of life. Manometric data showed normal small bowel motility in their jejunal limb. All three patients had normal MMC frequency and propagation velocity. The fasting pattern converted to fed motility pattern in all. Our study demonstrated that: (1) CG, although seemingly radical, is indicated and successful therapy for a subgroup of patients with refractory chronic gastroparesis following gastric surgery; (2) assessment of the gastric emptying of an isotope-labeled solid meal is crucial in identifying gastroparesis as the etiology of the patients' symptoms in the postgastric surgery setting; and (3) surgery involving stomal revisions or a Roux-en-Y procedure will not resolve the symptoms of chronic gastric atony, since these patients have an underlying gastric motility impairment without diffuse small bowel involvement.