b'Report from the Lead for Non-Malignant OG Disease Report fr om the Lead for Non-MalignanReport from the Lead f or Non-Malignant OG Diseaset OG DiseaseSymptoms:bloating,nauseawithorwithoutvomiting,in20%ofthetimeforthe1stand2ndinjectionbutstomach does not empty at all over the course of the 4 acidrefluxandupperabdominalpain;thenon-specifictolerance seems to develop and it stops working after thehours and none of the above therapies will work once this nature of the symptomatology makes the diagnosis more3rd injection. end stage disease is reached and the patient might benefit challenging.from having their stomach removed which is an extremely GastricElectricalStimulation:orbetterknownasthemorbid procedure and patients should not be allowed to DifferentialDiagnosis:includealmosteveryupperGIgastric pacemaker, is a device introduced and approved inreach that stage.pathologye.g.biliarydyspepsia,gastro-oesophagealthe US around 2001 (18 years ago). It is a modified cardiac reflux,gastritis,H-pyloriinfection,gastric/duodenalpacemaker but does not work as a pacemaker due to theGastric Bypass: paradoxically a minority of patients with ulcersleadingtoalongprocessofself-treatment,anature of the pathogenesis of gastroparesis.Autonomicvery severe gastroparesis are significantly overweight. It protracteddiagnosticworkuporevensurgicaltherapynervesthatsuppliestheintestinearenotlikeskeletalis important to remember that gastroparetics are able to for other pathologies such as gall stones or hiatal herniamuscle nerves; when the nerve to the skeletal muscles fires,tolerate some foods typically high calorie liquids and low without symptomatic relief before eventually reaching thethe electrical pulse causes the skeletal muscle to contractfibre foods leading in some cases to morbid obesity and diagnosis of gastroparesis. but the effect is the exact opposite in the intestine; whenthis group should be offered therapy in the form of gastric the autonomic nerve fires it causes the gastric muscle tobypass which has the added benefit of potential remission Types:diabetic(isatypeofneuropathy,5%oftyperelax. In gastroparesis, the nerves are injured and musclesof their diabetes (if they are diabetics), obesity-induced Professor Ashraf Rasheed 1diabeticsand1%oftype2diabeticswilldevelopare not relaxing at the right time and spasm could alsohigh blood pressure and sleep apnoea plus a resolution to symptomatic gastroparesis over their lifetime) and non- develop upon eating explaining why sometimes we seethe nausea.diabetic (idiopathic with a prevalence of 0.2% of the totalpatients who become nauseated and may even retch or It is with mixed emotions I write my final report as OG lead;population) which can be further sub-divided into post- vomit upon smell of food or following the first bite. TheSummary:takeagoodhistoryandoncethediagnosis but it is time for new blood and fresh ideas. It has beenviral(respiratory,flu-like,GIinfections,CMV,EBVandgastric stimulator re-innervates the pyloric muscles andis made refer to a dietician first.For the diabetics, once an epic journey and during the past 7 years, I learnt a lot,HZV) and post-surgical (1% incident of damage to the vagiit is thought to increase gastric accommodation helpingthey have been through that and have not improved offer met great people, made new friends and enjoyed everyduring hiatal hernia and anti-reflux surgery). Medicationsthe stomach to relax when the food comes down ratherpyloroplasty and a gastric stimulator at the same time.moment of it.I dedicate my last report to gastroparesis,e.g. opioids can also induce gastric slowing but this is notthanimproveemptying.ThisproposedexplanationisFor the idiopathic ones offer pyloroplasty with or without a subject that is considered hardly interesting or indeedreally gastroparesis. Diabetics tend to suffer with nausea,borne out of the accumulating evidence as despite thegastric stimulator.Most (75-80%) people report significant surgical by many. It is a challenging disease and I believevomitingandbloatingsymptoms,butlesspain;whilesignificantsymptomaticimprovementin75%ofcasesimprovement with this management strategy. For those that we see patients in our UGI clinics with the diseaseidiopathic tend to have nausea with less vomiting, but afollowing gastric stimulation, gastric emptying improveswho are still very symptomatic, still getting admitted to the withoutrealisingit.Haveyoueverwonderedofwhymuch higher incidence of epigastric abdominal pain (80- in only a small minority and the majority of patients whohospital, having involuntary weight loss, one may either yourperfectlyperformedcholecystectomyoryour90% of this group will have pain as number 1 symptom).have a stimulator do not empty better. This therapy seemsprogress to addition of a stimulator for the idiopathic, or immaculatelyexecutedanti-refluxsurgerywasnotPostviralgastroparesiscangetbetterwithtimeandto more affective in diabetics (80%) than idiopathic (50%)proceed to sub-total gastrectomy or gastric bypass for the mirrored with the due outcome?! It is entirely possiblesome might even achieve a spontaneous remission and Ipatients and should be the first line therapy for patientsdiabetics or underwent a combined therapy.that the gall bladder you removed or the hiatus hernia youhence would not consider therapy until a year or so afterwith diabetic gastroparesis but idiopathic patients should repaired was a complete innocent bystander and did notdiagnosis for this group. not be automatically denied it. And as upper GI surgeons, we may also encounter patients contribute to the symptomatology.withdebilitatinggastroparesispostoesophagectomyor Investigations:gastricemptyingstudyisnormallyLaparoscopicPyloroplasty:thisismoreinvasivethanasaresultofinadvertentvagalinjuryafteranti-reflux Gastroparesis performedusingTc99mlabelledtoDTPAisthegoldthe gastric stimulating and the published data suggestssurgeryandIwouldrecommendthesamediagnostic Welivesomuchofourlifearoundthetableandsostandard (50% of the radioactive meal should move out of75-80%improvementinsymptomsaswellasgastricandmanagementalgorithm.Iwouldalsorecommend many of our meaningful events in life are around eating.the stomach within 4 hours). Sometimes it is done over 2emptying after pyloroplasty (c.f. stimulator did not leadaddition of gastric emptying study as part of the routine And if you see enough of these patients you will realisehours which is fine if the test was really abnormal, but ifto an improvement in gastric emptying) especially in thework up prior to any intended re-do anti-reflux surgery how debilitating gastroparesis can be, and although it isit is borderline then a 4 hour study should be performed.idiopathic group. The current consensus opinion is thatand to perform pyloroplasty at the same setting if delayed more prevalent than previously thought, it continues toOther tests could be done such as breathe testing; wirelessdiabetics who are going to have a stimulator should begastric emptying is detected as this would lead to a better beunappreciatedandsub-optimallytreated.Itismycapsules (the patient ingest a capsule and we measure howoffered pyloroplasty to get the added benefit of increasedsymptomatic outcome in relation to abdominal bloating view that upper GI surgeons need to have an adequatelong it stays in the stomach based on change in the pH thatemptying.The2therapiesseemtobecomplimentaryand gas bloat syndrome.understanding of this disease as these patients tend tois sensed by a remote sensor). Endoscopy can be helpful,to each other and can be performed simultaneously or find their way to UGI clinics through many routes, usuallyso a full stomach after 12 hours of fasting is diagnostic of asequentially.And finally, I would like thank all my UGI surgical colleagues as possible biliary dyspepsia or gastro-oesophageal refluxdelayed gastric emptying.in Wales who elected me to the council and the council for andoccasionallywithasuspicionoforaconfirmedEndoscopic Pyloromyotomy: typically referred to as gastricgiving me the opportunity to hold the prestigious position diagnosisfollowingaratherprotractedroutefromourManagement: treatment of gastroparesis is multi-factorialper oral endoscopic myotomy (G-POEM) is an emergingof OG lead. I am really grateful to you all and I wish you physician colleagues and then even when the diagnosis isand the majority improve with dietary therapy i.e. avoidingtechniqueandfirstdescribedin2014.Thelimitedand AUGIS every success.confirmed, one enters a convoluted route trying to securethefoodsthatslowthestomachandnoteatinglargeavailable data suggests its effectiveness in management funding for the required treatment.meals, so the food has time to empty (although slowly)of gastroparesis in a variety of settings and considered anProfessor Ashraf Rasheedbefore it causes any side effects and hence every patientalternative to less non-invasive treatments e.g. dilatation Definition: gastroparesis is an objective functional delaywith gastroparesis should see a dietician but when theseor Botox injection and to the more invasive therapy i.e. in emptying of the stomach in absence of any mechanicalmeasures dont work or the patient become dependentlaparoscopicpyloroplasty.Thisishoweveranadvanced obstruction at the gastric outlet or proximal small bowelon naso-jejunal or jejnostomy feeding then one needs toendoscopic procedure with limited availability in the UK, (Itisasymptomofotherdiseaseprocessese.g.DM,refer to other available therapy without delay. and it is my view that UGI surgeons are best placed to Parkinsons, multiple sclerosis, connective tissue disorders,upskill to deliver this therapy.post infectious or iatrogenic). Botulinumtoxin(Botox)injection:Botoxisanaturally occurringcompoundthatwheninjectedintoamuscleGastrectomy: for the above therapies to work, they need it causes paralysis, so when it is injected into the pyloricto be delivered timely i.e. before developing a completely muscle, it keeps it open all the time and seems to workflaccid immotile stomach. In this end stage group the 16 AUGIS Winter 2019 Newsletter AUGIS Winter 2019 Newsletter 17'