Gastric Stimulation is an Option for Patients With Refractory Cyclical Vomiting Syndrome: One Year Follow up

Abstract

Background: Post-surgical gastroparesis (PSG) develops in up to 10% of patients who undergo intentional or inadvertent vagotomy and in up to 50% of patients undergoing surgery for gastric outlet obstruction. Dumping syndrome is also a possible outcome from these surgeries. Aim: The aims of this study were to: 1) describe the clinical features of patients presenting with PSG symptoms; 2) identify surgeries associated with PSG; 3) distinguish PSG from a possible Dumping Syndrome. Methods: Medical and surgical history, symptoms assessment (PAGI-SYM,PAGI -QOL, Beck Depression Inventory (BDI), State-Trait Anxiety Inventory (STAI), and standardized 4-hour radionuclide gastric emptying test (GET) on patients with at least 12 weeks of gastroparesis (GP) symptoms were performed. Data were analyzed from the ongoing NIDDK GP Registry. All results are presented as percent or mean ± SD. Results: Out of 571 patients, 23 (4 %) qualified as having PSG symptoms. Of these 19 (83%) were F; mean age 48.0±13.2 years; mean BMI 24.7 ±6.5 (61% had a BMI ≤ 24). The mean symptoms duration was 6 years and onset of GP symptoms was associated with the following surgeries: Nissen Fundoplication (52%), partial gastric resection (22%); myotomy or esophago-gastrectomy (9% each); and stomach stapling and vagotomy (4% each). 52% of patients had been hospitalized in the past year and nausea with abdominal pain was the major indication for 78% of these admissions. 52% were on prokinetics, 78% on antiemetics, 78% on PPI / H2 blockers and 26% were on narcotics. None of the patients underwent Botox and 1 had Enterra therapy. The results of GET separated patients with PSG symptoms into: Group A-17(74%) with delayed GETmean value of 43.3 %± 26% retention at 4h (min-14; max -100% ), and 9 (53%) of them had severely delayed gastric emptying (>35% retention at 4h) and Group B6 (26%) without delayed GET, with a mean of 5.3% food retention at 4 h (min-1, max-7%) and with 2 (33%) of these patients meeting the criterion for Dumping Syndrome with ≤30% retention at1h. Overall, the highest mean PAGI-SYM score was for nausea 3.7 ± 1.3(max 5) and early satiety at 3.7±1.3. 17% of all studied patients had severe depression by BDI, 30% had severe STAI score. The average PAGI-QOL score was 2.7±1.1; with the poorest QOL for the diet sub-score (1.6±1.2). There were no statistical differences in symptoms or psychological parameters between the two groups. Conclusions: 1) In the setting of post-gastric and -esophageal surgeries, symptoms associated with delayed, normal or rapid emptying of the stomach are clinically indistinguishable and only GET could guide further medical and therapeutic approaches 2) Nissen Fundoplication is now the major surgery associated with PSG symptoms and could be attributed to “accidental” vagal nerve injury during surgery.