Has anyone heard of modified RnY

[DSRIGGS]

As a treatment for Gastroparesis?

 

[DianaCox]

I don't know what is meant by "modified" but I did find this:

Surg Obes Relat Dis. 2014 Sep-Oct;10(5):795-9. doi: 10.1016/j.soard.2014.01.013. Epub 2014 Jan 29.
Gastric bypass surgery as treatment of recalcitrant gastroparesis.
Papasavas PK1, Ng JS2, Stone AM2, Ajayi OA3, Muddasani KP4, Tishler DS2.
Author information

Abstract
BACKGROUND:
Few treatments for idiopathic and diabetic gastroparesis exist beyond symptom management, and no study has described gastric surgery for gastroparesis in obese and morbidly obese patients. The objective of this study was to describe treatment of recalcitrant gastroparesis in obese adults with Roux-en-Y gastric bypass (RYGB) surgery.

METHODS:
A retrospective review was conducted of adult patients who underwent laparoscopic RYGB. Clinical data pre- and postsurgery and at a follow-up of up to 2 years were reviewed. Total symptom scores for gastroparetic symptom severity and frequency were compared presurgery and at follow-up using paired t tests.

RESULTS:
Seven obese and morbidly obese patients (body mass index [BMI] = 39.5, range = 33-54; 6 women) with idiopathic or diabeticgastroparesis reported marked symptom improvement, and total symptom scores significantly decreased after RYGB. All 4 patients who were taking prokinetics preoperatively no longer required their medication after surgery. Three patients required prolonged treatment with antinausea medications in the postoperative period. Mean BMI change was 9.1 units and mean percent excess weight lost was 71.6 lbs. No perioperative complications were experienced. Two required readmissions due to various concerns (dysphagia, nausea, anastomotic ulcer).

CONCLUSIONS:
In our cohort, no patients required the use of prokinetics after surgery and everyone experienced significant improvement in symptoms. Importantly, we found that RYGB is a safe surgical treatment for gastroparesis in obese patients. Our results indicate that gastroparesis, primarily believed to result in being underweight, can present in morbid obesity and can be markedly improved with RYGB.

Copyright © 2014 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.​

And this: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3722580/pdf/nihms489116.pdf

Am J Gastroenterol. 2013 Jan;108(1):18-37; quiz 38. doi: 10.1038/ajg.2012.373. Epub 2012 Nov 13.
Clinical guideline: management of gastroparesis.
Camilleri M1, Parkman HP, Shafi MA, Abell TL, Gerson L; American College of Gastroenterology.
Author information

Abstract
This guideline presents recommendations for the evaluation and management of patients with gastroparesis. Gastroparesis is identified in clinical practice through the recognition of the clinical symptoms and documentation of delayed gastric emptying. Symptoms from gastroparesis include nausea, vomiting, early satiety, postprandial fullness, bloating, and upper abdominal pain. Management of gastroparesis should include assessment and correction of nutritional state, relief of symptoms, improvement of gastric emptying and, in diabetics, glycemic control. Patient nutritional state should be managed by oral dietary modifications. If oral intake is not adequate, then enteral nutrition via jejunostomy tube needs to be considered. Parenteral nutrition is rarely required when hydration and nutritional state cannot be maintained. Medical treatment entails use of prokinetic and antiemetic therapies. Current approved treatment options, including metoclopramide and gastric electrical stimulation (GES, approved on a humanitarian device exemption), do not adequately address clinical need. Antiemetics have not been specifically tested in gastroparesis, but they may relieve nausea and vomiting. Other medications aimed at symptom relief include unapproved medications or off-label indications, and include domperidone, erythromycin (primarily over a short term), and centrally acting antidepressants used as symptom modulators. GES may relieve symptoms, including weekly vomiting frequency, and the need for nutritional supplementation, based on open-label studies. Second-line approaches include venting gastrostomy or feeding jejunostomy; intrapyloric botulinum toxin injection was not effective in randomized controlled trials. Most of these treatments are based on open-label treatment trials and small numbers. Partial gastrectomy and pyloroplasty should be used rarely, only in carefully selected patients. Attention should be given to the development of new effective therapies for symptomatic control.

Comment in​

• • Response to Arnold and Beaves. [Am J Gastroenterol. 2013]
  • Update on clinical guidelines for the management of gastroparesis. [Am J Gastroenterol. 2013]

SURGICAL TREATMENTS: VENTING GASTROSTOMY, GASTROJEUNOSTOMY, PYLOROPLASTY, AND GASTRECTOMY

Summary of Evidence

In patients with significant upper GI motility disorders, surgically placed venting gastrostomy, with or without a venting enterostomy, reduced hospitalization rate by a factor of 5 during the year after placement (163,164). Results of endoscopic venting (percutaneous endoscopic gastrostomy and direct percutaneous endoscopic jejunostomy) on nutritional outcomes and gastroparesis symptoms have not been formally studied and remain unclear. In an open-label study, patients experienced marked symptomatic improvement, weight was maintained, and total symptom score was reduced up to 3 years post venting gastrostomy (165). It is assumed that the same beneficial outcome occurs with percutaneous endoscopic gastrostomy, though this is not proven.

Several types of surgical interventions have been tried for treatment of gastroparesis: gastrojejunostomy, pyloromyotomy, and completion or subtotal gastrectomy. A recent study reported on a series of 28 patients with gastroparesis in whom pyloroplasty resulted in symptom improvement, with significant improvement in gastric emptying and reduction in the need for prokinetic therapy when followed at 3 months post surgery (166). It is unclear whether the efficacy of pyloroplasty depends on the residual antral motor function; thus, in the few diabetics included in the series, there was no significant improvement in gastric emptying (166), and further studies with longer follow-up are needed to determine overall efficacy and optimal candidates for pyloroplasty to treat gastroparesis. Completion or subtotal gastrectomy was applied most often for gastroparesis that followed gastric surgery for peptic ulcer disease (167,168); experience from tertiary referral centers suggests that, in carefully selected patients, major gastric surgery can relieve distressing vomiting from severe gastroparesis and improve quality of life (169,170) in seriously affected patients where risk of subsequent renal failure is high and where life expectancy is poor. The risk of malnutrition and weight loss following gastrectomy has to be weighed relative to the symptom relief. The use of completion or subtotal gastrectomy in patients with intact gastroparetic stomachs has not been favorable. Pyloroplasty may relieve symptoms in gastroparesis and is often combined with operative jejunal tube placement to support nutrition (166,171). Subtotal gastrectomy with Roux-Y reconstruction may be needed for gastric atony secondary to PSG (167). In patients undergoing surgical treatment for gastroparesis, a full-thickness gastric biopsy may be helpful to assess the pathologic basis associated with the patient’s gastroparesis (172–175).​

 

[DSRIGGS]

I am at work and on my phone so I will look when I get home but I think I read this yesterday as well. There was a Bariatric surgeon in California who posted on a page. I didn't recall the name.

As far as modified gastric by pass I don't know what it means either but a GI suggested this as one possible choice dealing with gastroparesis for Cameron.....the other option is a NFW.

The GI didn't mention vagal nerve stimulation but insurance won't cover that anyway even though it could potentially help with two serious health concerns for Cameron.

I hate the freaking medical world right now, to put it mildly.

Thanks for your response Dianna

 

[DSRIGGS]

Dr Charles Callery of San Diego is the guy who posted on a site called thinner times.

http://www.thinnertimesforum.com/topic/103155-gastroparesis-and-gastric-bypass/

 

[Barb1]

I had gastroparesis when my VBG surgery to DS was done and failed to heal correctly. It was horrible and it got to the point were only liquids would go through. Dr. Keshishian in California did the revision to that and it was the best money that was ever spent. I only wish I could have found a way to see him originally in 2010. I don't know all of Cameron's problems but I would bet if you contacted Dr. K by e-mail and explained the problems he wouldn't hesitate to try and answer your question's. He is a very special human being and a wonderful surgeon.

 

[DSRIGGS]

Thanks Barb. I was definitely thinking of consulting with him.

Cameron's situation is quite complicated so it will take a top notch surgeon as this will not be an easy fix as there is more than just gastroparesis going on....a wrap that has already been repaired once, a reported "short esophagus", a hernia repair that has herniated again and the suspected damaged vagus nerve. I have not had a chance to speak directly to the GI (just his notes emailed by his nurse) so I am not sure what the theory is behind the cause that a gbp would fix...is it pylorous not functioning properly so taking it out of equation? Yet you have the DS and functioning pylorus and your gastroparesis resolved...so I am going to need to get the theory when the time is right (he is battling treatment resistant depression now so we have to get that resolved first).


Thanks again for your story and suggestion and I am glad your gastroparesis resolved

 

[DSRIGGS]

Okay, so I reached out to Dr K yesterday and wow...you guys are not exaggerating when you say he is incredible. I sent him an email on an early Saturday morning (probably 5 AM Pacific) and within an hour I see that I have a missed call on my phone. Yep, it was Dr k and I called him back and he spent 45 minutes discussing Cameron's case with me and he doesn't even know me from Adam. He even profusely apologized for having to put me on hold to answer his phone because he was rounding. What a guy......we need so many more with his caring and helping attitude, not to mention his technical skills and outside the box thinking.

We discussed two potentially strong options -

1. The "Modified Gastric Bypass" - Like me, he was not exactly sure what our GI meant with that comment, however; he did say that he has done procedures for people with non structural defects (blockage/bezore) where anastomosed an RnY limb to the greater curvature of the stomach. A big anastomsis and this in effect acts as an overflow drain to allow the stomach contents to empty and bypasses the pylorus that is probably not functioning properly. He wants to review the surgical report from Cameron's last Nissen but he felt this would be a potentially strong option. He also wants me to speak with my GI (I already had a message in but that guy does not respond like Dr K...just the opposite) and find out exactly what he meant by Modified GBP and what surgeon he had in mind. Dr K said that the procedure he described is not technically difficult so many surgeons in the area should be more than qualified of doing a good job. I will gather information in that regard and compare to the other potential option.
2. Vagal Nerve Stimulation (Also referred to as GES - implant put in your chest and electrical leads are wrapped around the vagus nerve and electrical impulses sent to stimulate gastric emptying). This Enterra Device (brand name for Medtronic's product) is FDA approved on a humanitarian basis but for extreme cases where feeding tube is required. Cameron is not at that point so he would not qualify even though Dr K says there is great scientific data to back up this device as a good solution for people in Cameron's situation. One of Dr Marshall's partners at Peoria Surgical actually was doing a clinical trial for the Enterra device but he is retiring and none of his partners are picking it up...so shit out of luck there. Dr K suggested that I reach out directly to the manufacturer of the device as they should be able to help us find a trial as they have a vested interest.

I was very much relieved after this conversation with Dr K as definitely thought from what he understood about Cameron's case (I gave him history and sent the GI report including all the testing information) that there is a solution that will work for him.

 

[Larra]

Scott, I'm so glad there are viable options for Cameron. I am very hopeful that he can be helped.

 

[DSRIGGS]

Scott, I'm so glad there are viable options for Cameron. I am very hopeful that he can be helped.

Hi and thanks, Larra.

We are very hopeful that we can get some relief for Cameron. I know this can help his other issues as well if it works

 

[southernlady]

Glad to see Dr. K had some options to give y'all. And that he is so willing to be there for people regardless of whether or not they had surgery with him.

 

[brooklyngirl]

Wow, happy you're on the road to answers for Cameron, Scott!

 

[DSRIGGS]

Wow, happy you're on the road to answers for Cameron, Scott!

Thanks Lauren!

Sadly this is only one part of the battle. He is struggling mightily with Treatment Resistant Depression and we are searching for answers to that huge issue as well. If we can fix the Gastroparesis related issues I think it will help the depression a great deal because he hurts and feels like hell almost all the time. It sucks but our mental health care system is a POS and we are searching out some non FDA approved/Medicare covered treatments. The system is just not set up to handle people who really need help....so we continue to battle for answers/solutions. One of the potential treatments we are researching could cost as much as $20,000 for a 4-6 week initial treatment. That sucks but we will do what we have to do in order to give him a chance at life.

 

[brooklyngirl]

Thanks Lauren!

Sadly this is only one part of the battle. He is struggling mightily with Treatment Resistant Depression and we are searching for answers to that huge issue as well. If we can fix the Gastroparesis related issues I think it will help the depression a great deal because he hurts and feels like hell almost all the time. It sucks but our mental health care system is a POS and we are searching out some non FDA approved/Medicare covered treatments. The system is just not set up to handle people who really need help....so we continue to battle for answers/solutions. One of the potential treatments we are researching could cost as much as $20,000 for a 4-6 week initial treatment. That sucks but we will do what we have to do in order to give him a chance at life.

Wow, this poor kid has been through the ringer! Hoping something works for him, he's too young to suffer so much.

 

[Barb1]

Wow Scott how wonderful! I told you he was a awesome human being! He continues to amaze me everyday at how much he really cares!! My thoughts and prayers are with Cameron, you, and your entire family!!

 

[more2adore]

Dr. K is a freaking angel. So glad Cameron can get the surgical help he needs!