1. Advances in Gastroparesis Dmitry Oleynikov M.D, F.A.C.S Associate Professor of Surgery Joseph and Richard Still Faculty Fellow in Medicine Director of Minimally Invasive And Robotic Surgery University Of Nebraska School Of Medicine

2. Gastric Emptying Physiology 1.Fundus/body relaxation 2.Antral tirturation 3.Fluctuations in pyloric tone 4.Antro-pyloro-duodenal coordination 5.Sensory inputs a.CNS b.From the stomach (gastrin, secretin) c.From the small intestine

4. Definition The diagnosis of Gastroparesis is based on the presence of appropriate symptoms/signs, delayed gastric emptying, and the absence of an obstructing structural lesion in the stomach or small intestine.

5. Causes Idiopathic 39% –Functional dyspepsia (FD) –GERD –Post Viral syndrome Diabetes Type I and II 29% Post gastric surgery 13% –Vertical Banded Gastroplasty –Partial gastrectomy Parkinson’s Disease 4.8% Chronic Idiopathic intestinal Pseudoobstruction 4.1% Soykan et al. DDS 1998

6. Evaluation Gastric emptying scintigraphy –Minimum 2 hours but greater than 4 can be more accurate Breath testing –nonradioactive isotope 13 C to label octanoate, a medium-chain triglyceride Antroduodenal manometry –Decreased antral contractility and originating fast Migrating motor complex (MMC) in small intestines

8. Treatment Primary treatment includes dietary modification and antiemetics and prokinectic agents Dietary modifications –Low fat diet –Frequent small meals –Replacing solids with liquid calories i.e. soup and protein shakes

9. Treatment Prokinetic agents –Metoclopramide and erythromycin are most common agents –Cisapride although associated with cardiac arrhythmias not available in US –Muscarinic cholinergic agents (bethanechol), –Anticholinesterases (pyridostigimine) –Serotonin agonist (i.e. tegaserod )

10. Treatment Antiemetics –Antiemetic agents are are administered for nausea and vomiting. –antidopaminergics, antihistamines, anticholinergics, and serotonin receptor antagonists –phenothiazine compounds i.e. prochlorperazine, trimethobenzamide, and promethazine at a

11. Treatment Prokinetic agents –Erythromycin –Metoclopramide –Cisapride

12. Refractory to medications Botulism toxin injection into pylorus Gastric electrical stimulation or pacing Surgery treating symptoms i.e. gastrostomy tube placement or nutritional support i.e. jejunostomy tube placement Gastric resection i.e. subtotal or total gastrectomy for severe intractable gastroparesis

13. Endoscopic Injection of Botox Small case series show improvement in emptying after injection of botulism toxin Clinical studies fail to show any benefit to this procedure. Arts J, et. al Aliment Pharmacol Ther. 2007;26(9):1251-8.

14. Gastric Electrical Stimulation (GES) The device (Enterra, Medtronic) approved by the FDA through a humanitarian device exemption GES involves the use of electrodes, usually placed laparoscopically into musculature of antrum Unclear how the stimulation works May control symptoms but not cure disease state RCT w/ 33 pts with idiopathic or diabetic gastroparesis, electrical stimulation no effect on symptoms overall but reduced the weekly frequency of vomiting (p<0.05). Abell T et al. Gastric electrical stimulation for medically refractory gastroparesis Gastroenterology. 2003;125(2):421-8.

17. Gastrectomy for Gastroparesis Total or subtotal gastrectomy may relieve symptoms of nausea and vomiting Roux-en-y reconstruction preferred to limit bile reflux 6 out of 7 patients had complete resolution of symptoms as well as follow up to 6 years Watkins et al. Long-term outcome after gastrectomy or intractable diabetic gastroparesis. Diabetic Medicine, 20: 58–63.

18. Morbid Obesity and Gastroparesis In our unpublished series of 6 pts with morbid obesity and gastroparesis, pts symptoms improved with laparoscopic vertical sleeve gastrectomy and had significant weight loss 4 of 6 pts had severe symptoms and completely resolved. Will repeat gastric emptying study once patients are over one year

19. Conclusion Gastroparesis is a difficult condition to manage. Medical therapy still remains the mainstay treatment New technologies still show no significant advantage over medical treatment Laparoscopic Vertical Sleeve Gastrectomy may provide benefit to morbid obese and diabetic pts with gastroparesis