A gastroenterologist’s view of post- surgical complications and gastroparesis George...
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Transcript of A gastroenterologist’s view of post- surgical complications and gastroparesis George...
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