Department of General Surgery and the Bariatric and Metabolic Institute, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA.
Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
Surg Endosc. 2024 Oct;38(10):6026-6032. doi: 10.1007/s00464-024-11099-w. Epub 2024 Aug 7.
Surgical treatments of refractory gastroparesis include pyloromyotomy and gastric electrical stimulator (GES). It is unclear if patients may benefit from a combined approach with concomitant GES and pyloromyotomy.
Retrospective cohort analysis of all patients with refractory gastroparesis treated with GES implantation with and without concomitant pyloromyotomy at Cleveland Clinic Florida from January 2003 to January 2023. Primary endpoint was efficacy (clinical response duration and success rate) and secondary endpoints included safety (postoperative morbidity) and length of stay. Success rate was defined as the absence of one of the following reinterventions during follow-up: Roux-en-Y gastric bypass (RYGB), pyloromyotomy, GES removal.
During a period of 20 years, 134 patients were treated with GES implantation. Three patients with history of previous surgical pyloromyotomy or RYGB were excluded from the analysis. Median follow-up was 31 months (IQR 10, 72). Forty patients (30.5%) had GES with pyloromyotomy, whereas 91 (69.5%) did not have pyloromyotomy. Most of the patients had idiopathic (n = 68, 51.9%) or diabetic (n = 58, 43.3%) gastroparesis. Except for preoperative use of opioids (47.5 vs 14.3%; p < 0.001), patient's characteristics were similar in both groups. There were no significant differences between the two groups in terms of overall postoperative complications (17.5% vs 14.3%; p = 0.610), major postoperative complications (0% vs 2.2%; p = 1), and length of stay (2(IQR 1, 2) vs 2(IQR 1, 3) days; p = 0.068). At 5 years, success rate was higher in patients with than without pyloromyotomy however not statistically significant (82% versus 62%, p = 0.066). Especially patients with diabetic gastroparesis seemed to benefit from pyloromyotomy during GES (100% versus 67%, p = 0.053). In an adjusted Cox regression, GES implantation without pyloromyotomy was associated with a 2.66 times higher risk of treatment failure compared to GES implantation with pyloromyotomy (HR 2.66, 95% CI 1.03-6.94, p = 0.044).
Pyloromyotomy during GES implantation for gastroparesis seems to be associated with a longer clinical response with similar postoperative morbidity and length of hospital stay than GES without pyloromyotomy. Patient with diabetic gastroparesis might benefit from a combination of GES implantation and pyloromyotomy.
胃轻瘫的手术治疗包括幽门肌切开术和胃电刺激（GES）。目前尚不清楚患者是否可以从同时进行 GES 和幽门肌切开术的联合治疗中获益。
对 2003 年 1 月至 2023 年 1 月期间在克利夫兰诊所佛罗里达州接受 GES 植入治疗的难治性胃轻瘫患者进行回顾性队列分析，同时接受和不接受幽门肌切开术。主要终点是疗效（临床反应持续时间和成功率），次要终点包括安全性（术后发病率）和住院时间。成功率定义为在随访期间没有进行以下一种再干预：Roux-en-Y 胃旁路术（RYGB）、幽门肌切开术、GES 去除。
在 20 年的时间里，有 134 名患者接受了 GES 植入治疗。有 3 名患者有既往手术性幽门肌切开术或 RYGB 的病史，因此被排除在分析之外。中位随访时间为 31 个月（IQR 10，72）。40 名患者（30.5%）接受了 GES 联合幽门肌切开术，而 91 名患者（69.5%）未接受幽门肌切开术。大多数患者患有特发性（n=68，51.9%）或糖尿病性（n=58，43.3%）胃轻瘫。除了术前使用阿片类药物（47.5%比 14.3%；p<0.001）外，两组患者的特征相似。两组患者的总体术后并发症（17.5%比 14.3%；p=0.610）、主要术后并发症（0%比 2.2%；p=1）和住院时间（2（IQR 1，2）比 2（IQR 1，3）天；p=0.068）无显著差异。在 5 年时，接受幽门肌切开术的患者的成功率高于未接受者，但无统计学意义（82%比 62%，p=0.066）。特别是糖尿病性胃轻瘫患者似乎从 GES 期间的幽门肌切开术获益（100%比 67%，p=0.053）。在调整后的 Cox 回归中，与接受 GES 植入术但未接受幽门肌切开术的患者相比，接受 GES 植入术且同时接受幽门肌切开术的患者治疗失败的风险高 2.66 倍（HR 2.66，95%CI 1.03-6.94，p=0.044）。
与不接受幽门肌切开术的 GES 植入术相比，GES 植入术治疗胃轻瘫时同时进行幽门肌切开术似乎与更长的临床反应时间相关，且术后发病率和住院时间相似。糖尿病性胃轻瘫患者可能从 GES 植入和幽门肌切开术的联合治疗中获益。
