Living with gastroparesis can be debilitating and result in frequent visits to the emergency room for nausea, vomiting and pain. The good news is treatment of gastroparesis has evolved significantly in recent years and our team knows how to get you back to living a full life again.
PYLOROPLASTY PROCEDURE
What is a pylorus?
The role of the stomach is to turn solid food into liquid. The pylorus is a sphincter muscle at the end of the stomach that stays closed while the stomach is digesting solid food. Once food is liquefied, branches of the vagus nerve signal the pylorus to open, letting food empty into the small intestine. With gastroparesis, inflammation damages these nerves so the pylorus cannot open normally. This creates a blockage at the end of the stomach. When the stomach cannot empty, it blows up with swallowed air, fluid, and food to make patients feel sick.
What is a pyloroplasty?
The symptoms of gastroparesis are due to the stomach not emptying normally. Pyloroplasty decompresses the stomach into your small intestine (the direction food is supposed to flow) rather than up your esophagus (heartburn) and out your mouth (nausea and vomiting). In this procedure, the pylorus is cut open and then sewn shut in a crosswise fashion so that it remains wide open allowing food to pass through more easily.
What’s involved?
This procedure can typically be performed laparoscopically which involves using a camera through several small incisions. This is an outpatient procedure, it takes about an hour, and you are able to go home the same day.
Watch a Video of an Actual Pyloroplasty Surgery
(WARNING: IMAGES MAY BE DISTURBING TO SOME)
What about Botox injections and G-POEM or POP? Can they help?
An endoscope can be used to inject Botox into the pylorus. With very early stage disease, this can relax the muscles of the pylorus allowing it to open and the stomach to empty. The effect is only temporary, so repeated injections are necessary.
As gastroparesis progresses, inflammation replaces the muscle with scar tissue called fibrosis. Once there is fibrosis, Botox is no longer effective. As the fibrosis gets thicker, the pylorus gets tighter. This creates progressive stomach blockage.
An endoscope can also be used to cut the muscle of the pylorus. This is called a pyloromyotomy. When done endoscopically, a pyloromyotomy is called G-POEM or POP. Many people, including doctors, think pyloromyotomy and pyloroplasty are the same, but they are not. Click here to check out our blog post that discusses this in much more detail.
Similar to Botox, pyloromyotomy may work for those that have not yet developed fibrosis. Pyloroplasty works regardless how fibrotic the pylorus has become. At Vanguard Surgical, we do not offer Botox injections or G-POEM/POP because patients typically have a fibrotic pylorus by the time they see a doctor.
Pyloroplasty is the most effective therapy and never needs to be repeated. While more invasive than the endoscopic procedures, it is an outpatient, home same day procedure. Having done nearly 2,000 laparoscopic pyloroplasty procedures, Dr. Hughes' rate of significant complications is <0.5%.
What can I expect after pyloroplasty?
Immediately after the surgery, the pyloric channel will be wide open. However, overnight it will swell and narrow back down. During this time, you may feel no better than before the surgery and will need to limit your diet to liquids and pureed, soft, and mashed foods. Click here to learn more about your diet while recovering from pyloroplasty.
You will have two phases of improvent. During the first month, the swelling goes away and the pyloroplasty opens back up. During the third month, the suture dissolves so that it can stretch open further. As you feel better, you can gradually start reintroducing solid food.
If you gave up on nausea medication (such as promethazine and/or ondansetron) because they didn’t work, then you might try them again. They may be much more effective once the pyloroplasty is fully open and your stomach is decompressed.
What if pyloroplasty does not help me?
For most patients (about 2/3), pyloroplasty is all they need. With the stomach emptying better and no longer under pressure, the nausea typically improves as the Vagus nerve is no longer signaling the brain to make them sick. For reasons that we do not fully understand, some patients (about 1/3) have persistent nausea even after the stomach is decompressed with pyloroplasty. For these patients, we can place a gastric stimulator to treat the left-over nausea. If you are one of these patients, then the pyloroplasty is still useful, as we likely will not need to turn the gastric stimulator up as high as we would have if you did not have the pyloroplasty.
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What about dumping syndrome?
Dumping syndrome has been seen in some patients after pyloroplasty when done for stomach ulcers, not for gastroparesis.
Decades ago, before we had effective antacid medication, surgeons would cut the vagus nerve to shut down acid production and heal ulcers. Knowing that cutting the vagus nerve would result in the pylorus staying shut, surgeons would perform pyloroplasty at the same time. Prior to surgery, these ulcer patients emptied their stomachs normally.
After surgery, they would sometimes empty too fast, particularly with a carbohydrate-rich meal. This would result in diarrhea, lightheadedness, low blood sugar and even passing out. The treatment would be to reduce carbohydrates and increase fat and protein to slow down digestion. As a gastroparesis patient with delayed emptying, we want you to empty more quickly. We also want you to be better able to tolerate a diet balanced with fats and proteins.