a gastroenterologist’s view of post- surgical complications and gastroparesis george...
TRANSCRIPT
![Page 1: A gastroenterologist’s view of post- surgical complications and gastroparesis George Triadafilopoulos, MD Clinical Professor of Medicine Stanford University](https://reader036.vdocuments.mx/reader036/viewer/2022081519/56649e465503460f94b3ade3/html5/thumbnails/1.jpg)
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
![Page 2: A gastroenterologist’s view of post- surgical complications and gastroparesis George Triadafilopoulos, MD Clinical Professor of Medicine Stanford University](https://reader036.vdocuments.mx/reader036/viewer/2022081519/56649e465503460f94b3ade3/html5/thumbnails/2.jpg)
Outline
• What can happen
• How do we find out
• What can we do about it
![Page 3: A gastroenterologist’s view of post- surgical complications and gastroparesis George Triadafilopoulos, MD Clinical Professor of Medicine Stanford University](https://reader036.vdocuments.mx/reader036/viewer/2022081519/56649e465503460f94b3ade3/html5/thumbnails/3.jpg)
What can happen…
![Page 4: A gastroenterologist’s view of post- surgical complications and gastroparesis George Triadafilopoulos, MD Clinical Professor of Medicine Stanford University](https://reader036.vdocuments.mx/reader036/viewer/2022081519/56649e465503460f94b3ade3/html5/thumbnails/4.jpg)
![Page 5: A gastroenterologist’s view of post- surgical complications and gastroparesis George Triadafilopoulos, MD Clinical Professor of Medicine Stanford University](https://reader036.vdocuments.mx/reader036/viewer/2022081519/56649e465503460f94b3ade3/html5/thumbnails/5.jpg)
Reasons for revisional surgery
%
N=109 pts
Lamb et al. Br J Surg. 2009;96(4):391-7
![Page 6: A gastroenterologist’s view of post- surgical complications and gastroparesis George Triadafilopoulos, MD Clinical Professor of Medicine Stanford University](https://reader036.vdocuments.mx/reader036/viewer/2022081519/56649e465503460f94b3ade3/html5/thumbnails/6.jpg)
Esophagus – Diagnostic Steps
![Page 7: A gastroenterologist’s view of post- surgical complications and gastroparesis George Triadafilopoulos, MD Clinical Professor of Medicine Stanford University](https://reader036.vdocuments.mx/reader036/viewer/2022081519/56649e465503460f94b3ade3/html5/thumbnails/7.jpg)
Barium studies
![Page 8: A gastroenterologist’s view of post- surgical complications and gastroparesis George Triadafilopoulos, MD Clinical Professor of Medicine Stanford University](https://reader036.vdocuments.mx/reader036/viewer/2022081519/56649e465503460f94b3ade3/html5/thumbnails/8.jpg)
Intra-thoracic wrap migration
Revisional surgery
![Page 9: A gastroenterologist’s view of post- surgical complications and gastroparesis George Triadafilopoulos, MD Clinical Professor of Medicine Stanford University](https://reader036.vdocuments.mx/reader036/viewer/2022081519/56649e465503460f94b3ade3/html5/thumbnails/9.jpg)
![Page 10: A gastroenterologist’s view of post- surgical complications and gastroparesis George Triadafilopoulos, MD Clinical Professor of Medicine Stanford University](https://reader036.vdocuments.mx/reader036/viewer/2022081519/56649e465503460f94b3ade3/html5/thumbnails/10.jpg)
Endoscopy: Intact fundoplication
![Page 11: A gastroenterologist’s view of post- surgical complications and gastroparesis George Triadafilopoulos, MD Clinical Professor of Medicine Stanford University](https://reader036.vdocuments.mx/reader036/viewer/2022081519/56649e465503460f94b3ade3/html5/thumbnails/11.jpg)
Multichannel intraluminal impedance assesses esophageal
clearance
![Page 12: A gastroenterologist’s view of post- surgical complications and gastroparesis George Triadafilopoulos, MD Clinical Professor of Medicine Stanford University](https://reader036.vdocuments.mx/reader036/viewer/2022081519/56649e465503460f94b3ade3/html5/thumbnails/12.jpg)
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%).
![Page 13: A gastroenterologist’s view of post- surgical complications and gastroparesis George Triadafilopoulos, MD Clinical Professor of Medicine Stanford University](https://reader036.vdocuments.mx/reader036/viewer/2022081519/56649e465503460f94b3ade3/html5/thumbnails/13.jpg)
Pneumatic dilation for crural stenosis: 85% successful
![Page 14: A gastroenterologist’s view of post- surgical complications and gastroparesis George Triadafilopoulos, MD Clinical Professor of Medicine Stanford University](https://reader036.vdocuments.mx/reader036/viewer/2022081519/56649e465503460f94b3ade3/html5/thumbnails/14.jpg)
![Page 15: A gastroenterologist’s view of post- surgical complications and gastroparesis George Triadafilopoulos, MD Clinical Professor of Medicine Stanford University](https://reader036.vdocuments.mx/reader036/viewer/2022081519/56649e465503460f94b3ade3/html5/thumbnails/15.jpg)
Stomach/Intestine – Diagnostic Steps
![Page 16: A gastroenterologist’s view of post- surgical complications and gastroparesis George Triadafilopoulos, MD Clinical Professor of Medicine Stanford University](https://reader036.vdocuments.mx/reader036/viewer/2022081519/56649e465503460f94b3ade3/html5/thumbnails/16.jpg)
Gastric emptying study in gastroparesis
![Page 17: A gastroenterologist’s view of post- surgical complications and gastroparesis George Triadafilopoulos, MD Clinical Professor of Medicine Stanford University](https://reader036.vdocuments.mx/reader036/viewer/2022081519/56649e465503460f94b3ade3/html5/thumbnails/17.jpg)
Nissen vs Toupet fundoplication
![Page 18: A gastroenterologist’s view of post- surgical complications and gastroparesis George Triadafilopoulos, MD Clinical Professor of Medicine Stanford University](https://reader036.vdocuments.mx/reader036/viewer/2022081519/56649e465503460f94b3ade3/html5/thumbnails/18.jpg)
Gas-bloat symptoms post NissenDigestive and Liver Disease 39 (2007) 312–318
![Page 19: A gastroenterologist’s view of post- surgical complications and gastroparesis George Triadafilopoulos, MD Clinical Professor of Medicine Stanford University](https://reader036.vdocuments.mx/reader036/viewer/2022081519/56649e465503460f94b3ade3/html5/thumbnails/19.jpg)
Gas-bloat symptoms post ToupetDigestive and Liver Disease 39 (2007) 312–318
![Page 20: A gastroenterologist’s view of post- surgical complications and gastroparesis George Triadafilopoulos, MD Clinical Professor of Medicine Stanford University](https://reader036.vdocuments.mx/reader036/viewer/2022081519/56649e465503460f94b3ade3/html5/thumbnails/20.jpg)
Bloating before and after fundoplication +/- pyloroplasty
World J Surg. 2007;31(2):332-6
*
![Page 21: A gastroenterologist’s view of post- surgical complications and gastroparesis George Triadafilopoulos, MD Clinical Professor of Medicine Stanford University](https://reader036.vdocuments.mx/reader036/viewer/2022081519/56649e465503460f94b3ade3/html5/thumbnails/21.jpg)
Concomitant pyloroplasty improves gastric emptying in GERD patients
with gastroparesisWorld J Surg. 2007;31(2):332-6
![Page 22: A gastroenterologist’s view of post- surgical complications and gastroparesis George Triadafilopoulos, MD Clinical Professor of Medicine Stanford University](https://reader036.vdocuments.mx/reader036/viewer/2022081519/56649e465503460f94b3ade3/html5/thumbnails/22.jpg)
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
![Page 23: A gastroenterologist’s view of post- surgical complications and gastroparesis George Triadafilopoulos, MD Clinical Professor of Medicine Stanford University](https://reader036.vdocuments.mx/reader036/viewer/2022081519/56649e465503460f94b3ade3/html5/thumbnails/23.jpg)
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
![Page 24: A gastroenterologist’s view of post- surgical complications and gastroparesis George Triadafilopoulos, MD Clinical Professor of Medicine Stanford University](https://reader036.vdocuments.mx/reader036/viewer/2022081519/56649e465503460f94b3ade3/html5/thumbnails/24.jpg)
Pyloric motility and BoTox injection for gastroparesis
![Page 25: A gastroenterologist’s view of post- surgical complications and gastroparesis George Triadafilopoulos, MD Clinical Professor of Medicine Stanford University](https://reader036.vdocuments.mx/reader036/viewer/2022081519/56649e465503460f94b3ade3/html5/thumbnails/25.jpg)
Pyloric BoTox for gastroparesis
% improvement at 2 months, n=6
Ezzedine et al. GIE. 2002;55:920-3
![Page 26: A gastroenterologist’s view of post- surgical complications and gastroparesis George Triadafilopoulos, MD Clinical Professor of Medicine Stanford University](https://reader036.vdocuments.mx/reader036/viewer/2022081519/56649e465503460f94b3ade3/html5/thumbnails/26.jpg)
Enterra® for refractory post-
surgical gastroparesis% improvement at 60 months n=31
McCallum et al .CGH 2011
![Page 27: A gastroenterologist’s view of post- surgical complications and gastroparesis George Triadafilopoulos, MD Clinical Professor of Medicine Stanford University](https://reader036.vdocuments.mx/reader036/viewer/2022081519/56649e465503460f94b3ade3/html5/thumbnails/27.jpg)
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
![Page 28: A gastroenterologist’s view of post- surgical complications and gastroparesis George Triadafilopoulos, MD Clinical Professor of Medicine Stanford University](https://reader036.vdocuments.mx/reader036/viewer/2022081519/56649e465503460f94b3ade3/html5/thumbnails/28.jpg)
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