title: Surgical treatment of medically refractory gastroparesis in the morbidly obese.
abstract: BACKGROUND
  Surgical management of medically refractory gastroparesis remains a challenge. Case series and small retrospective studies describe clinical benefits from surgical intervention; however, no study reports the efficacy of gastric electrical stimulation (GES) or Roux-en-Y gastrojejunostomy with or without near-total gastrectomy (RYGJ) in morbidly obese patients with severe gastroparesis.
  
  
  METHODS
  A chart review was performed on all morbidly obese patients (BMI > 35 kg/m(2)) who underwent GES or RYGJ for medically refractory gastroparesis from March 2002 to December 2012 at the Cleveland Clinic. The main outcomes examined were symptom improvement, postoperative complications, and change in BMI.
  
  
  RESULTS
  A total of 20 morbidly obese patients underwent GES placement. Seven morbidly obese patients had RYGJ with or without resection of the remnant stomach surgery. All operations were completed laparoscopically. In GES group, 18 patients had initial symptom improvement (90%) and 11 (55%) rated their symptom improved at the last follow-up. During the average 23 months' follow-up, 9 patients (45%) experienced at least one readmission for gastrointestinal reasons. Early complications included two infections at a simultaneously placed J-tube site and one seroma. In the RYGJ group, all patients, including 4 patients who failed GES and subsequently converted to RYGJ, experienced short-term symptom improvement and 5 patients (71%) rated their symptoms as improved at last follow-up. One duodenal stump leak happened in the RYGJ group. There were no 30-day mortalities in either group. The BMI change after GES implantation was 0.6 ± 4 kg/m(2) versus -7.7 ± 4 kg/m(2) after RYGJ (p < 0.01).
  
  
  CONCLUSIONS
  GES implantation and RYGJ are both effective in terms of symptom control for medically refractory gastroparesis in morbidly obese. Both options can be performed in a minimally invasive fashion with low morbidity. Patients who have no improvement of symptoms for refractory gastroparesis after GES implantation can be successfully converted laparoscopically to RYGJ.
authors.affiliation: Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, USA, sunz2@ccf.org.
authors.forename: Zhuo
authors.initials: Z
authors.lastname: Sun
authors.forename: John
authors.initials: J
authors.lastname: Rodriguez
authors.forename: John
authors.initials: J
authors.lastname: McMichael
authors.forename: Bipan
authors.initials: B
authors.lastname: Chand
authors.forename: Deanne
authors.initials: D
authors.lastname: Nash
authors.forename: Stacy
authors.initials: S
authors.lastname: Brethauer
authors.forename: Phillip
authors.initials: P
authors.lastname: Schauer
authors.forename: Kevin
authors.initials: K
authors.lastname: El-Hayek
authors.forename: Matthew
authors.initials: M
authors.lastname: Kroh
mesh_terms: D000328:Adult; D004599:Electric Stimulation Therapy; D005260:Female; D005743:Gastrectomy; D015390:Gastric Bypass; D018589:Gastroparesis / Q000628:therapy*; D006801:Humans; D010535:Laparoscopy; D008297:Male; D009767:Obesity, Morbid / Q000601:surgery*; D012189:Retrospective Studies