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.
There is a drug that is available in Canada and I believe for compassionate use in the US called Domperidone (it is not the French bubbly drink, but probably costs more). We have one patient on it with diabetic gastroparesis and she thinks it helps.
I was trained at Mayo Clinic regarding this exact scenario; time is the best treatment in this situation. That is, just wait. You have done everything medically and surgically possible. Often these patients will recover from their gastric atony over six to eight weeks. Keeping up with the pro-kinetic medications, and the nutrition, and tincture of time.
It appears that the stoma is patent and I assume that you are certain that there is NO distal small bowel obstruction or some sort of SMA-duodenal compression syndrome.
Erythromycin’s effectivity in promoting gastric emptying has been proven, metocloramide’s not. I do not think that you can add anything else. The best therapy of postvagotomy gastroparesis is PATIENCE: wait and it will resolve within 6-8 weeks. Let the old man walk about-it may help.
I have never found any of the prokinetic agents to be much help. I had a very similar case in an elderly woman after vagotomy and antrectomy which resolved after 6 weeks of NG suction and TPN.
Well, could there be a kink at the jejunostomy feeding site? the feeding would go by, but an obstruction could exist for proximal secretions. I would feed in a long tube into the 3rd part of the duodenum and get a gastrograffin study.
I was concerned also that my feeding tube site might be the sight of the obstruction. The feeding tube was out at the time of Gastrografin Upper GI series. There was no obstruction in the small intestine.
I have since replaced the feeding tube with a Dobbhoff type weighted feeding tube, which is in the distal duodenum on X-ray, so the feeding tube is above the feeding tube entrance site.
I too agree that “tincture of time” mixed with jejunostomy tube feedings is the optimal way to treat the delayed gastric emptying found after gastric resection, particularly after Roux-en-Y anastomoses…especially those done in the face of preoperative gastric outlet obstruction.
One suggestion….I have found that the use of urecholine injections, which are then eventually changed to oral tablets can be quite beneficial. These can then be weaned and discontinued in the outpatient arena, usually continuing the Reglan for a few more weeks. Whether this regimen was truly beneficial or it just helped me buy some more “tincture of time”, however, is uncertain.