Gastroparesis after vagotomy & antrectomy

Does anyone have any new ideas on relentless gastroparesis after vagotomy and antrectomy?

I have an 83 year old otherwise healthy patient who had multiple small gastric and duodenal ulcers. He presented acutely with bleeding. He was treated appropriately with multiple ulcer medications and continued to bleed slowly over the next 1.5 weeks.

I performed a vagotomy and antrectomy with EEA (Ethicon version) gastroduodenostomy and he initially did reasonably well. He did require Reglan for gastric emptying. He has a jejunostomy for tube feedings. Finally, he was eating adequately and off tube feedings.

I sent him to a neighboring hospital Swing Bed program where he promptly developed a small bowel obstruction. He had a very long redundant sigmoid colon which had wrapped itself around the upper border of his feeding jejunostomy site and kinked some mid-jejunal loops. I divided all the adhesions, resected the redundant sigmoid and replaced the jejunostomy.

He received intravenous hyperalimentation after his second surgery. I restarted his jejunostomy feedings after his small intestinal and colon function returned.

He is now tolerating his jejunostomy feedings adequately, but he still has high NG output. Gastrografin UGI series seemed to show an anastomotic stricture, so I gastroscoped him. The scope went easily through the anastomosis and I even balloon dilated it to make sure there was no blockage (yesterday). His NG output is still 600 cc per shift—it is a little yellow (bile from duodenum) but does not contain tube feedings.

He is on Reglan (metoclopramide) and erythromycin to improve gastric emptying.

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