Management of the patient with gastroparesis

Choosing wisely: Enteral feeding tube selection, placement, and considerations before and beyond the procedure room

When an enteral feeding tube (EFT) is placed, it is not always known how long this nutrition support intervention will be needed. As a result, the type of device the patient originally has placed may not match the function it is required to serve or the lifestyle needs of the patient throughout their enteral nutrition journey. Medicare considers an EFT a prosthetic device, as it is replacing a permanently inoperable or nonfunctioning organ. If we think about an EFT the same way we think about a prosthetic limb, one that needs to be customized to meet all of the patient's functional and lifestyle needs, we can also begin to think beyond the procedure room and carefully consider a variety of factors that impact the patient at home receiving enteral nutrition. Proper fit, function, and style is essential in order for the patient to have a positive relationship with their EFT, contributing to their successful home enteral nutrition experience. Clinicians who care for these patients in any setting and in any capacity would benefit from enhancing their understanding of available EFT options, their design components, and available methods of placement. Many home care and outpatient clinicians adopt the role of patient advocate as it relates to a patient's enteral nutrition journey, and this expanded knowledge could be used to benefit the patient by improving their overall enteral nutrition experience and ultimately their relationship with their "prosthetic."

Bio-impedance method to monitor colon motility response to direct distal colon stimulation in anesthetized pigs

Electrical stimulation has been demonstrated as an alternative approach to alleviate intractable colonic motor disorders, whose effectiveness can be evaluated through colonic motility assessment. Various methods have been proposed to monitor the colonic motility and while each has contributed towards better understanding of colon motility, a significant limitation has been the spatial and temporal low-resolution colon motility data acquisition and analysis. This paper presents the study of employing bio-impedance characterization to monitor colonic motor activity. Direct distal colon stimulation was undertaken in anesthetized pigs to validate the bio-impedance scheme simultaneous with luminal manometry monitoring. The results indicated that the significant decreases of bio-impedance corresponded to strong colonic contraction in response to the electrical stimulation in the distal colon. The magnitude/power of the dominant frequencies of phasic colonic contractions identified at baseline (in the range 2-3 cycles per minute (cpm)) were increased after the stimulation. In addition, positive correlations have been found between bio-impedance and manometry. The proposed bio-impedance-based method can be a viable candidate for monitoring colonic motor pattern with high spatial and temporal resolution. The presented technique can be integrated into a closed-loop therapeutic device in order to optimize its stimulation protocol in real-time.

The effect of colonic tissue electrical stimulation and celiac branch of the abdominal vagus nerve neuromodulation on colonic motility in anesthetized pigs

BACKGROUND

Knowledge on optimal electrical stimulation (ES) modalities and region-specific functional effects of colonic neuromodulation is lacking. We aimed to map the regional colonic motility in response to ES of (a) the colonic tissue and (b) celiac branch of the abdominal vagus nerve (CBVN) in an anesthetized porcine model.

METHODS

In male Yucatan pigs, direct ES (10 Hz, 2 ms, 15 mA) of proximal (pC), transverse (tC), or distal (dC) colon was done using planar flexible multi-electrode array panels and CBVN ES (2 Hz, 0.3-4 ms, 5 mA) using pulse train (PT), continuous (10 min), or square-wave (SW) modalities, with or without afferent nerve block (200 Hz, 0.1 ms, 2 mA). The regional luminal manometric changes were quantified as area under the curve of contractions (AUC) and luminal pressure maps generated. Contractions frequency power spectral analysis was performed. Contraction propagation was assessed using video animation of motility changes.

KEY RESULTS

Direct colon ES caused visible local circular (pC, tC) or longitudinal (dC) muscle contractions and increased luminal pressure AUC in pC, tC, and dC (143.0 ± 40.7%, 135.8 ± 59.7%, and 142.0 ± 62%, respectively). The colon displayed prominent phasic pressure frequencies ranging from 1 to 12 cpm. Direct pC and tC ES increased the dominant contraction frequency band (1-6 cpm) power locally. Pulse train CBVN ES (2 Hz, 4 ms, 5 mA) triggered pancolonic contractions, reduced by concurrent afferent block. Colon contractions propagated both orally and aborally in short distances.

CONCLUSION AND INFERENCES

In anesthetized pigs, the dominant contraction frequency band is 1-6 cpm. Direct colonic ES causes primarily local contractions. The CBVN ES-induced pancolonic contractions involve central neural network.

Endoscopic and Surgical Treatments for Gastroparesis: What to Do and Whom to Treat?

Gastroparesis is a complex chronic debilitating condition of gastric motility resulting in the delayed gastric emptying and multiple severe symptoms, which may lead to malnutrition and dehydration. Initial management of patients with gastroparesis focuses on the diet, lifestyle modification and medical therapy. Various endoscopic and surgical interventions are reserved for refractory cases of gastroparesis, not responding to conservative therapy. Pyloric interventions, enteral access tubes, gastric electrical stimulator and gastrectomy have been described in the care of patients with gastroparesis. In this article, the authors review current management, indications, and contraindications to these procedures.

Long-limb Roux-en-Y Reconstruction after Subtotal Gastrectomy to Treat Severe Diabetic Gastroparesis

The role of surgical intervention in patients with diabetic gastroparesis is unclear. We report a case of a 37-year-old man with a history of recurrent episodes of vomiting and long-standing type 2 diabetes mellitus. Esophagogastroduodenoscopy did not reveal any findings of reflux esophagitis or obstructive lesions. A gastric emptying time scan showed prolonged gastric emptying half-time (344 minutes) indicating delayed gastric emptying. Laboratory tests revealed elevated fasting serum glucose and glycosylated hemoglobin (HbA1c, 12.9%) and normal fasting C-peptide and insulin levels. We performed Roux-en-Y reconstruction after subtotal gastrectomy to treat gastroparesis and improve glycemic control, and the patient showed complete resolution of gastrointestinal symptoms postoperatively. Barium swallow test and gastric emptying time scan performed at follow-up revealed regular progression of barium and normal gastric emptying. Three months postoperatively, his fasting serum glucose level was within normal limits without the administration of insulin or oral antidiabetic drugs with a reduced HbA1c level (6.9%). Long-limb Roux-en-Y reconstruction after subtotal gastrectomy may be useful to treat severe diabetic gastroparesis by improving gastric emptying and glycemic control.

Lubiprostone improves visualization of small bowel for capsule endoscopy: a double-blind, placebo-controlled 2-way crossover study

BACKGROUND AND STUDY AIMS

 Lubiprostone has been reported to be an anti-constipation drug. The aim of the study was to investigate the usefulness of lubiprostone both for bowel preparation and as a propulsive agent in small bowel endoscopy.

PATIENTS AND METHODS

 This was a double-blind, placebo-controlled, 2-way crossover study of subjects who volunteered to undergo capsule endoscopy (CE). A total of 20 subjects (16 male and 4 female volunteers) were randomly assigned to receive a 24-μg tablet of lubiprostone 120 minutes prior to capsule ingestion for CE (L regimen), or a placebo tablet 120 minutes prior to capsule ingestion for CE (P regimen). Main outcome was gastric transit time (GTT) and small-bowel transit time (SBTT). Secondary outcome was adequacy of small-bowel cleansing and the fluid score in the small bowel. The quality of the capsule endoscopic images and fluid in the small bowel were assessed on 5-point scale.

RESULTS

 The capsule passed into the small bowel in all cases. Median GTT was 57.3 (3 - 221) minutes for the P regimen and 61.3 (10 - 218) minutes for the L regimen ( P  = 0.836). Median SBTT was 245.0 (164 - 353) minutes for the P regimen and 228.05 (116 - 502) minutes for the L regimen ( P  = 0.501). The image quality score in the small bowel was 3.05 ± 1.08 for the P regimen and 3.80 ± 0.49 for the L regimen ( P  < 0.001). The fluid score in the small bowel was 2.04 ± 1.58 for the P regimen and 2.72 ± 1.43 for the L regimen ( P  < 0.001). There was a significant difference between the 2 regimens with regard to image quality. The fluid score was more plentiful for the L regimen than for the P regimen. There were no cases of capsule retention or serious adverse events in this study.

CONCLUSION

 Our study showed that use of lubiprostone prior to CE significantly improved visualization of the small bowel during CE as a result of inducing fluid secretion into the small bowel.

Histologic changes in diabetic gastroparesis

The cellular abnormalities that lead to diabetic gastroparesis are increasingly being understood. Several key cell types are affected by diabetes, leading to gastroparesis. These changes include abnormalities in the extrinsic innervation to the stomach, loss of key neurotransmitters at the level of the enteric nervous system, smooth muscle abnormalities, loss of interstitial cells of Cajal, and changes in the macrophage population resident in the muscle wall. This article reviews the current understanding with a focus on data from human studies when available.

Lubiprostone decreases the small bowel transit time by capsule endoscopy: an exploratory, randomised, double-blind, placebo-controlled 3-way crossover study

The aim of this study was to investigate the usefulness of lubiprostone for bowel preparation and as a propulsive agent in small bowel endoscopy. Six healthy male volunteers participated in this randomized, 3-way crossover study. The subjects received a 24 μg tablet of lubiprostone 60 minutes prior to the capsule ingestion for capsule endoscopy (CE) and a placebo tablet 30 minutes before the capsule ingestion (L-P regimen), a placebo tablet 60 minutes prior to CE and a 24 μg tablet of lubiprostone 30 minutes prior to CE (P-L regimen), or a placebo tablet 60 minutes prior to r CE and a placebo tablet again 30 minutes prior to CE (P-P regimen). The quality of the capsule endoscopic images and the amount of water in the small bowel were assessed on 5-point scale. The median SBTT was 178.5 (117-407) minutes in the P-P regimen, 122.5 (27-282) minutes in the L-P regimen, and 110.5 (11-331) minutes in the P-L regimen (P = 0.042). This study showed that the use of lubiprostone significantly decreased the SBTT. We also confirmed that lubiprostone was effective for inducing water secretion into the small bowel during CE.

Benefits of acupuncture for diabetic gastroparesis: a comparative preliminary study

OBJECTIVES

The aim of this preliminary study was to compare the effectiveness of domperidone and acupuncture for the management of diabetic gastroparesis.

METHODS

This was a preliminary, prospective non-randomised, unblinded case-crossover study conducted in patients with longstanding, uncontrolled diabetes mellitus and gastroparesis. All patients received domperidone (20 mg four times a day) for 12 weeks, followed by a 2-3 week washout period, and then biweekly acupuncture treatments for 8 weeks. Gastric emptying rate, glucose and glycated haemoglobin (HbA1C) levels were measured at start and end of each treatment period. At each of these timepoints patients completed the Gastroparesis Cardinal Symptom Index (GCSI), the Satisfaction with Life Scale (SWLS), and the Short-Form 36 Health Survey Update (SF-36).

RESULTS

The trial was curtailed after only eight participants could be recruited in 3 years. The mean age of patients was 57.1±9.9 years, the male:female ratio was 1:7 and mean body mass index (kg/m(2)) was 25.2±1.2. There was no change in any of the outcome parameters after treatment with domperidone. Acupuncture was associated with a decrease in scores for almost all cardinal symptoms of the GCSI, as well as in increased total score on the SWLS (p=0.002) and the social functioning domain of the SF-36 (p=0.054). Acupuncture did not lead to an improvement in gastric emptying, or glucose control from baseline.

CONCLUSIONS

Acupuncture treatment may lead to symptomatic improvement in patients with diabetic gastroparesis. Within the limitations of this preliminary, non-randomised and unblinded study, it appears that this effect may be due to non-specific mechanisms.

Muscular vs. Neural Activation in Propulsion Induced by Electrical Stimulation in the Descending Colon of Rats

The present experiments were performed on rat colon to study neurogenic and myogenic elicited propulsion induced by 0.3 and 30 msec long current pulses. The colon segments were stimulated sequentially and randomly. The obtained contractions displaced the intraluminal content in individual propulsion steps. The propulsion steps differed in displacement onset latency, distance, and velocity; the latency decreased while the distance and velocity increased from the proximal to the distal colon segments when performing sequential stimulation; the propulsion steps differed in latency when stimulation was performed randomly; the latency in the first propulsion step was three times longer when using 0.3 vs. 30 msec long pulses. When inhibiting cholinergic transmission by atropine, the propulsion induced by 0.3 msec pulses was blocked, while partially inhibited when using 30 msec pulses. Inhibiting nitric oxide synthesis by N(G) -nitro-L-arginine methyl ester (L-NAME) blocked propulsion induced by both of the pulse durations. In conclusion, electrical stimulation induces propulsion when using both 0.3 and 30 msec long pulses; stimulation using 0.3 msec pulses activates neurons, whereas 30 msec pulses depolarize muscles; in the absence of nitrergic transmission, propulsion cannot be induced by electrical stimulation.

Postgastrectomy nutrition

Gastric resection, whether partial or total gastrectomy, often results in nutrition-related complications including weight loss, diet intolerances, and micronutrient deficiencies. The physiology of normal and postgastrectomy digestion is the basis for most of the current diet recommendations after gastric surgery. A careful review reveals that there is not sufficient literature to support a standard postgastrectomy diet. Rather, individualized diet manipulation for symptom relief is recommended. This review highlights the physiology behind common postgastrectomy complications, provides guidelines for the medical and nutrition management of these complications, and presents a basic approach to postgastrectomy gastrointestinal symptoms.

Assessment of functional delayed gastric emptying after laparoscopic reconstructive gastric surgeries

AIM: To identify possible predictors of functional delayed gastric emptying (FDGE) after laparoscopic reconstructive gastric surgeries.

METHODS: The clinical data for 471 patients who underwent laparoscopic reconstructive gastric surgeries (including laparoscopic fundoplication, repair of hiatal hernia, adjustable gastric banding and Heller myotomy) from January 2001 to December 2009 were collected and analyzed retrospectively.

RESULTS: The possible predictors of FDGE after laparoscopic reconstructive gastric surgeries include: age over 65 years, a history of diabetes, preoperative hypoproteinemia, anxiety disorder, duration of surgery longer than 150 min, and preoperative abdominal infection (all P < 0.05).

CONCLUSION: The etiology of FDGE after laparoscopic reconstructive gastric surgeries is multi-factorial. The above-mentioned predictors are high risk factors for postoperative FDGE.

Luteolin reduces high glucose-mediated impairment of endothelium-dependent relaxation in rat aorta by reducing oxidative stress

While luteolin, a flavone rich in many plants, has some cardiovascular activity, it is not clear whether luteolin has beneficial effects on the vascular endothelial impairment in hyperglycemia/high glucose. Here, we reveal the protective effect of luteolin on endothelium-dependent relaxation in isolated rat aortic rings exposed to high glucose. The thoracic aorta of male Sprague-Dawley rats was rapidly dissected out and the effect of luteolin on the tension of aortic rings pretreated with high glucose (44mM) for 4h was measured in an organ bath system. The levels of nitric oxide (NO), hydroxy radical (OH(-)) and reactive oxygen species (ROS), and the activity of superoxide dismutase (SOD) and nitric oxide synthase (NOS) were measured in aortas. The vasorelaxation after treatment with luteolin for 8 weeks in aortic rings from diabetic rats was also determined. We found that exposure to high glucose decreased acetylcholine-induced endothelium-dependent relaxation. However, high mannitol had no effect on vasorelaxation. Luteolin evoked a concentration-dependent relaxation in aortic rings previously contracted by phenylephrine, and the pD(2) value was 5.24+/-0.04. The EC(50) of luteolin markedly attenuated the inhibition of relaxation induced by high glucose, which was significantly weakened by pretreatment with l-NAME (0.1mM), but not by indomethacin (0.01mM). Luteolin significantly inhibited the increase of ROS level and OH(-) formation, and the decrease of NO level, NOS and SOD activity caused by high glucose. The improving effect of luteolin on endothelium-dependent vasorelaxation in diabetic rat aortic rings was reversed by pretreatment with l-NAME or methylene blue. The results indicate that the decrease of endothelium-dependent relaxation in rat aortic rings exposed to high glucose is markedly attenuated by luteolin, which may be mediated by reducing oxidative stress and enhancing activity in the NOS-NO pathway.

Treatment of dysautonomia in extrapyramidal disorders

Although extrapyramidal diseases are commonly thought to solely affect the extrapyramidal motor system, nonmotor symptoms such as behavioural abnormalities, dysautonomia, sleep disturbances and sensory dysfunctions are also frequently observed. Autonomic dysfunction as an important clinical component of extrapyramidal disease (idiopathic Parkinson's disease, multiple system atrophy, progressive supranuclear palsy, dementia with Lewy bodies) is often not formally assessed and thus frequently misdiagnosed. Symptoms of autonomic dysfunction in general impact more on quality of life than motor symptoms. Appropriate symptom-oriented diagnosis and symptomatic treatment as part of an interdisciplinary approach can greatly benefit the patient. Unfortunately, double-blind, randomized, controlled studies are scarce with the consequence that most recommendations are not based on the highest level of evidence. This review elaborates a limited overview on the treatment of cardiovascular, gastrointestinal, urogenital and sudomotor autonomic dysfunction in various extrapyramidal syndromes.

Diabetic gastroparesis: diagnosis and management

Gastric emptying is frequently abnormal in patients with long-standing type 1 and type 2 diabetes mellitus. Symptoms commonly associated with disordered gastric emptying include nausea, vomiting, bloating and epigastric pain, while patients are also at risk of malnutrition, weight loss, impaired drug absorption, disordered glycaemic control and poor quality of life. Although often attributed to the presence of irreversible autonomic neuropathy, acute hyperglycaemia represents a potentially reversible cause of gastric dysfunction in diabetes. Scintigraphy represents the gold standard for measuring gastric emptying. The management of diabetic gastroparesis is less than optimal, partly because the pathogenesis has not been clearly defined. Treatment approaches include dietary modification and optimization of glycaemia, and the use of prokinetic drugs, while novel therapies such as gastric electrical stimulation are the subject of ongoing investigation.

Post-pyloric feeding

Postpyloric feeding is an important and promising alternative to parenteral nutrition. The indications for this kind of feeding are increasing and include a variety of clinical conditions, such as gastroparesis, acute pancreatitis, gastric outlet stenosis, hyperemesis (including gravida), recurrent aspiration, tracheoesophageal fistula and stenosis in gastroenterostomy. This review discusses the differences between pre- and postpyloric feeding, indications and contraindications, advantages and disadvantages, and provides an overview of the techniques of placement of various postpyloric devices.

A case of life-threatening nausea and vomiting

Nausea and vomiting are symptoms frequently occurring in the presence of cancer. However, a patient with known cancer may also have a benign cause for nausea and vomiting. This case report of a patient with early gastric carcinoma demonstrates this point, and is a caution against attributing worsening symptoms to worsening cancer. The patient had severe postoperative gastroesophageal reflux and gastroparesis following proximal partial gastrectomy. Ultimately, the nausea and vomiting were totally relieved by completion gastrectomy.

Clinical impact of a newly developed capsule endoscope: usefulness of a real-time image viewer for gastric transit abnormality

BACKGROUND

A new capsule endoscope has been developed by Olympus Medical Systems. The visualization and usefulness of its real-time image viewer for gastric transit abnormality were evaluated by using this new device.

METHODS

Thirty-seven consecutive patients were enrolled. In cases of gastric transit abnormality (gastric transit > 60 min, detected by the real-time viewer), intramuscular metoclopramide (10 mg) was administered. Diagnostic yield and gastric and small bowel transit times in ten patients receiving (group A) and 27 not receiving (group B) metoclopramide were analyzed.

RESULTS

Median gastric transit time was longer in group A than in group B (110 vs. 24 min; P < 0.0001). Conversely, median small bowel transit time was shorter in group A than in group B (270 vs. 347 min; P < 0.05). Further, small bowel transit was complete in 9/10 patients (90%) in group A, and in 23/27 patients (85%) in group B, but the difference was not significant. Overall diagnostic yield was 78% (29/37 patients), and there was no significant difference in the ratio of abnormal findings documented between group A (8/10, 80%) and group B (21/27, 78%) patients.

CONCLUSIONS

This new technology allowed clear image interpretation, and the real-time viewer was useful for detecting gastric transit abnormalities and determining a need for metoclopramide administration in patients undergoing capsule endoscopy.

Therapy Insight: gastrointestinal complications of diabetes--pathophysiology and management

Patients with diabetes often have gastrointestinal symptoms, but the extent and severity of this problem and the specificity of the symptoms are not nearly as well defined as frequently assumed. Any part of the gastrointestinal tract can be affected, and the presenting symptoms depend on the composite of dysfunctional elements. Gastroesophageal reflux, Candida esophagitis, gastroparesis, diarrhea and constipation are among the many common gastrointestinal complications of diabetes. No specific risk factor for the development of these complications has been identified and their etiology is most likely to be multifactorial, involving both reversible and irreversible processes. Treatment should be directed at tighter glycemic and symptom control, which can bring about clinical improvement for many patients. For other patients, however, effective clinical management is problematic because no therapies are available to prevent or correct the underlying disease mechanisms. Studies now suggest that reduced levels of key trophic factors cause transdifferentiation of pacemaker interstitial cells of Cajal into a smooth-muscle-like phenotype. If this really is the case, therapies directed at restoring the normal milieu of trophic signals could correct the dysfunction of the interstitial cells of Cajal and resolve many gastrointestinal complications. Advances in stem cell technology also hold promise to provide a cure for diabetes and to correct abnormalities in gastrointestinal pathology.

Omentoplasty in rectal cancer surgery prolongs post-operative ileus

BACKGROUNDS AND AIM

Omentoplasty is frequently used as a safeguard in rectal cancer surgery for wrapping the anastomosis or filling up the pelvic cavity. The omentum is known for its infection defence and haemostatic and angiogenic properties. A disadvantage was hypothesized to be prolonged post-operative ileus, as omentoplasty interrupts the blood flow from an epiploic artery to the stomach.

MATERIALS AND METHODS

Patients who had had an uncomplicated surgical treatment for primary rectal cancer between January 2006 and March 2007 were included. Clinical parameters of post-operative ileus were collected and compared between procedures with a concomitant omentoplasty (n = 31) and without (n = 20).

RESULTS

Patients needed their gastric tube significantly longer after omentoplasty than those without (3.9 vs 1.6 days, p < 0.001). Similar significant results were found for time to normal diet (p = 0.004), time to first discharge of faeces (p = 0.007), need for parenteral feeding (p = 0.036) and length of hospital stay (p = 0.008). Furthermore, there was a non-significant trend for more days to first discharge of air (3.4 vs 2.4 days, p = 0.165). There were no significant differences in patients' and procedure characteristics, except for more low anterior resections in the group without an omentoplasty (p < 0.001). None of these characteristics had any clinically relevant interference with the parameters of post-operative ileus.

CONCLUSION

A trend for prolonged post-operative ileus was found in patients who underwent an omentoplasty concomitant with their treatment for primary rectal cancer. When assessing the importance of omentoplasty in the future, post-operative ileus should be taken into account.

Clinical application prospects of gastric pacing for treating postoperative gastric motility disorders

Similar to the heartbeat, gastric peristalsis is regulated by an electrical rhythm generated by a pacemaker. Thus, electrical dysrhythmia of gastric slow waves will inevitably affect gastric peristalsis and emptying. The recurrence of postoperative gastroparesis is thereby closely related to the abnormalities of electrical dysrhythmia and ectopic pacemakers, resulting in postoperatively persistent gastric motility disorders in some severe cases, despite the use of prokinetic and antiemetic drugs. Recent studies have demonstrated that gastric pacing, analogous to pacing the human heart, is an attractive and promising therapy that is both feasible and safe. Gastric pacing has been shown to be strikingly effective in normalizing gastric dysrhythmia, increasing the activity of the gastric slow wave and thereby prompting gastric dynamia and emptying. Furthermore, the long-term utilization of gastric pacing can (i) relieve patients from clinical symptoms, such as nausea and vomiting; (ii) release patients with severe postoperative gastroparesis from relying on prokinetic drugs and the jejunal feeding tube; (iii) return patients to normal oral nutritional intake and provide a more satisfactory nutritional status and most importantly; and (iv) give patients a better quality of life. Overall, research focused on gastric pacing has demonstrated excellent prospects for clinical application in the treatment of postoperative gastroparesis disorders, especially for those unresponsive to prokinetic drugs.

Rational prescription of drugs within similar therapeutic or structural class for gastrointestinal disease treatment: Drug metabolism and its related interactions

AIM: To review and summarize drug metabolism and its related interactions in prescribing drugs within the similar therapeutic or structural class for gastrointestinal disease treatment so as to promote rational use of medicines in clinical practice.

METHODS: Relevant literature was identified by performing MEDLINE/Pubmed searches covering the period from 1988 to 2006.

RESULTS: Seven classes of drugs were chosen, including gastric proton pump inhibitors, histamine H₂-receptor antagonists, benzamide-type gastroprokinetic agents, selective 5-HT₃ receptor antagonists, fluoroquinolones, macrolide antibiotics and azole antifungals. They showed significant differences in metabolic profile (i.e., the fraction of drug metabolized by cytochrome P450 (CYP), CYP reaction phenotype, impact of CYP genotype on interindividual pharmacokinetics variability and CYP-mediated drug-drug interaction potential). Many events of severe adverse drug reactions and treatment failures were closely related to the ignorance of the above issues.

CONCLUSION: Clinicians should acquaint themselves with what kind of drug has less interpatient variability in clearance and whether to perform CYP genotyping prior to initiation of therapy. The relevant CYP knowledge helps clinicians to enhance the management of patients with gastrointestinal disease who may require treatment with polytherapeutic regimens.

Gastric emptying in diabetic patients by the (13)C-octanoic acid breath test: role of insulin in gastric motility

BACKGROUND

Impairment of gastric emptying is well recognized in patients with diabetes mellitus (DM), especially long-standing insulin-dependent diabetes mellitus (IDDM). The aim of this study was to evaluate the cause of delayed gastric emptying in DM patients.

METHODS

In 16 controls, 16 non-insulin-dependent diabetes mellitus (NIDDM) patients and 23 IDDM patients, gastric emptying was studied using the (13)C octanoic acid breath test. Breath samples were taken before a test meal labeled with 100 mg of (13)C octanoic acid, and at 15-min intervals over a 300-min period postprandially.

RESULTS

In all DM patients, the gastric emptying coefficient was lower than that in the controls (P < 0.05), and lag time and half-emptying time were significantly longer (P < 0.05). Both NIDDM and IDDM patients showed delayed (13)CO(2) excretion compared with the controls, but IDDM patients showed more delayed gastric emptying than NIDDM patients (P < 0.05). There were no significant differences in sex, HbA1c level, or the rate of neuropathy between the two groups.

CONCLUSIONS

IDDM patients showed delayed gastric emptying compared with NIDDM patients, and the (13)C octanoic acid breath test is useful for evaluating DM patients with delayed gastric emptying.

Video-capsule endoscopy gastric and small bowel transit time and completeness of the examination in patients with diabetes mellitus

BACKGROUND

Small intestine video-capsule endoscopy examination in patients with diabetes mellitus may be incomplete due to delayed gastric emptying.

AIM

To measure video-capsule endoscopy gastric and small bowel transit time and to assess the completeness of the examination in diabetes mellitus patients.

METHODS

In this retrospective, case-control study, we examined capsule endoscopy videos from 29 consecutive diabetes mellitus patients. Fifty-eight matched for sex, type of preparation, age and reason for referral non-diabetic controls were selected from our video-capsule endoscopy database. Two independent experienced investigators measured transit times and assessed examinations' completeness.

RESULTS

Video-capsule endoscopy gastric transit time was significantly longer in diabetes mellitus (87, 1-478 min) compared to non-diabetic patients (24, 4-108 min, p<0.001). The caecum was visualized in 20/29 (69%) diabetes mellitus and 52/58 (89.6%) non-diabetic controls (p=0.02). In 16 diabetes mellitus patients that video-capsule endoscopy reached the caecum, small bowel transit time was significantly shorter (261.2+/-55.5 min) compared to their 32 non-diabetic matched controls (302+/-62.7 min, p=0.03).

CONCLUSIONS

Patients with type 2 diabetes mellitus have prolonged video-capsule endoscopy gastric transit time compared to non-diabetic patients. Prospective studies are required to complete our understanding of video-capsule endoscopy transit times in the setting of diabetes mellitus.

Pathophysiology and management of diabetic gastropathy: a guide for endocrinologists

Delayed gastric emptying is frequently observed in patients with long-standing type 1 and type 2 diabetes mellitus, and potentially impacts on upper gastrointestinal symptoms, glycaemic control, nutrition and oral drug absorption. The pathogenesis remains unclear and management strategies are currently suboptimal. Therapeutic strategies focus on accelerating gastric emptying, controlling symptoms and improving glycaemic control. The potential adverse effects of hyperglycaemia on gastric emptying and upper gut symptoms indicate the importance of normalising blood glucose if possible. Nutritional and psychological supports are also important, but often neglected. A number of recent pharmacological and non-pharmacological therapies show promise, including gastric electrical stimulation. As with all chronic illnesses, a multidisciplinary approach to management is recommended, but there are few data regarding long-term outcomes.

Advances in mechanisms of postsurgical gastroparesis syndrome and its diagnosis and treatment

Postsurgical gastroparesis syndrome (PGS) is a complex disorder characterized by post-prandial nausea and vomiting, and gastric atony in the absence of mechanical gastric outlet obstruction, and is often caused by operation at the upper abdomen, especially by gastric or pancreatic resection, and sometimes also by operation at the lower abdomen, such as gynecological or obstetrical procedures. PGS occurs easily with oral intake of food or change in the form of food after operation. These symptoms can be disabling and often fail to be alleviated by drug therapy, and gastric reoperations usually prove unsuccessful. The cause of PGS has not been identified, nor has its mechanism quite been clarified. PGS after gastrectomy has been reported in many previous studies, with an incidence of approximately 0.4-5.0%. PGS is also a frequent complication of pylorus-preserving pancreatoduodenectomy (PPPD), and the complication occurs in the early postoperative period in 20-50% of patients. PGS caused by pancreatic cancer cryoablation (PCC) has been reported about in 50-70% of patients. Therefore, PGS has a complex etiology and might be caused by multiple factors and mechanisms. The frequency of this complication varies directly with the type and number of gastric operations performed. The loss of gastric parasympathetic control resulting from vagotomy contributes to PGS via several mechanisms. It has been reported that the interstitial cells of Cajal (ICC) may play a role in the pathogenesis of PGS. Recent studies in animal models of diabetes suggest specific molecular changes in the enteric nervous system may result in delayed gastric emptying. The absence of the duodenum, and hence gastric phase III, may be a cause of gastric stasis. It was thought that PGS after PPPD might be attributable, at least in part, to delayed recovery of gastric phase III, due to lowered concentrations of plasma motilin after resection of the duodenum. The damage to ICC might play a role in the pathogenesis of PGS after PCC, for which multiple factors are possibly responsible, including ischemic and neural injury to the antropyloric muscle and the duodenum after freezing of the pancreatoduodenal regions or reduction of circulating levels of motilin. As the treatment of gastroparesis is far from ideal, non-conventional approaches and non-standard medications might be of use. Multiple treatments are better than single treatment. This article reviews almost all the papers related to PGS from various journals published in English and Chinese in recent years in order to facilitate a better understanding of PGS.

Relationships between hypoglycaemia and gastric emptying abnormalities in insulin-treated diabetic patients

We hypothesize that hypoglycaemia in insulin-treated diabetic patients may result from gastric emptying abnormalities causing insulin and food absorption mismatching. We tested gastric emptying in insulin-treated diabetic patients with unexplained hypoglycaemia and without dyspepsia and in diabetic patients without hypoglycaemia, prospectively. Thirty-one diabetic patients with unexplained hypoglycaemic events within 2 h of insulin injection and 18 insulin-treated diabetic patients without hypoglycaemic events underwent gastric emptying breath tests, glycaemic control and autonomic nerve function. Gastric emptying tests were abnormal in 26 (83.9%) and in four (22.2%) patients with and without hypoglycaemia, respectively (P < 0.001). Gastric emptying was significantly slower in hypoglycaemic diabetic patients (t1/2 139.9 +/- 74.1 vs 77.8 +/- 23.3 and t(lag) 95.8 +/- 80.3 vs 32.84 +/- 16.95 min, P < 0.001 for both comparisons; t-tests). A significant association between hypoglycaemic patients and abnormal values of t1/2 and t(lag) was found (P < 0.001). Gastric emptying abnormalities were more frequent in hypoglycaemic patients. We suggest gastric emptying tests for diabetic patients with unexplained hypoglycaemic events.

Colon emptying induced by sequential electrical stimulation in rats

Electrical stimulation could be used to induce colon emptying. The present experiments were performed to establish a stimulation pattern to optimize the stimulation parameters and to test neural involvement in propulsion induced by electrical stimulation. Colon segments were sequentially stimulated using rectangular pulses. The resulting propulsive activity displaced intraluminal content in consecutive propulsion steps. The propulsion steps differed in displacement latency, distance, and velocity along the stimulated colon. Increasing the pulse duration or amplitude resulted in a decrease of the latency. Increasing the stimulation amplitude doubled the displacement distance. The frequencies tested in the present study did not affect propulsion. Inhibition of cholinergic and nitrergic pathways inhibited propulsion. Electrical stimulation can induce colonic propulsion. Motor differences are present along the descending colon. The most suitable combination of pulse parameters regarding colon stimulation is 0.3 ms, 5 mA, 10 Hz. Neural circuits are involved in propulsion when using these values.

Nutrition and motility disorders

The purpose of this article is to give an overview of the relation between feeding and gastrointestinal symptoms and complaints, and to review different motility disorders that have implications for food intake. We also report the consequences for nutrition state and the evidence-based principles of dietary modification in patients with motility disorders.

Electrical stimulation for gastroparesis

BACKGROUND

Gastroparesis is a disabling, and sometimes fatal, disease that often does not respond to medical treatment. This single-surgeon prospective study examines the safety and 6-month efficacy of electrical stimulation for the treatment of gastroparesis.

METHODS

Sixteen patients with medically refractory gastroparesis underwent laparoscopic implantation of an electrical stimulator device (Enterra Therapy, Medtronic, Minneapolis, MN, USA) consisting of a subcutaneous stimulator and two gastric wall leads. Gastric emptying scans (GES) confirmed the diagnosis of gastroparesis. Patients were evaluated preoperatively using a self-administered GI symptomatology questionnaire and RAND 36 Health Survey. Once patients were >6-months from implantation, a repeat GES was obtained and patients completed a postoperative GI symptomatology questionnaire and RAND 36 Health Survey. Ten of 16 patients in this case series were >6-months from implantation. One was lost to follow-up. An F-test was used to establish equality of standard deviations between the 16 patients evaluated preoperatively and the subset of 10 patients evaluated postoperatively. A Student's t-test was used to evaluate the significance of differences in pre- and postoperative results.

RESULTS

Average operating time was 117 min with no intraoperative complications. The majority of patients were discharged on postoperative day 1. There were two complications in the postoperative period. Patients experienced a significant decrease in nausea and vomiting as measured by the GI symptomatology questionnaire. Half of all patients no longer required gastric prokinetic medications and there was a subjective reduction of pyrosis, early satiety, and epigastric pain. A significant increase in quality of life as measured by the RAND 36 Health Survey was seen, and six of eight patients no longer demonstrated gastroparesis on GES.

CONCLUSION

Laparoscopic implantation of an electrical stimulation device is a safe and effective treatment by subjective and objective standards for the management of medically refractory gastroparesis.

New management approaches for gastroparesis

Management of patients with gastroparesis is challenging. Although the syndrome has multiple causes and knowledge of the pathophysiology and natural history is far from complete, a number of common management principles can be applied. The relatively poor correlation between upper-gastrointestinal symptoms and disordered gastric emptying represents a major difficulty in the therapeutic approach, and evidence to support the efficacy of current management strategies is often suboptimal, especially in relation to long-term therapy. In this review, the common causes and pathophysiology of gastroparesis are summarized, the diagnostic approach considered, and the evidence to support medical and surgical therapies reviewed. These therapies include currently available prokinetic drugs, novel medical therapies, and the promising technique of gastric electrical stimulation.

Propulsive activity induced by sequential electrical stimulation in the descending colon of the pig

This work was performed to study electrically induced contractions in the descending colon of pigs. Contractions were monitored using impedance planimetry and manometry. The luminal pressure, cross-sectional area (CSA), latency and velocity of CSA decrease were compared when using 3 ms, 9, 12, 15 or 30 mA pulses at 10 Hz for 10 s, and 15 mA, 0.03, 0.3 or 3 ms pulses at 10 Hz for 10 s. Stimulation was performed prior and after the application of N(G)-nitro-L-arginine methyl ester (L-NAME) and atropine. In the untreated colon, contraction was always of an 'off' type. A current increase from 9 to 30 mA increased the pressure. An increase of pulse duration from 0.03 to 3 ms shortened the latency, accelerated contraction and increased pressure. By sequential stimulation, contractions were coordinated to propel semi-fluid and solid luminal contents. L-NAME increased the magnitude of CSA decrease. Atropine induced inhibitory effects on contractions elicited by 3 ms pulses and abolished contractions induced by 0.03 and 0.3 ms pulses.

IN CONCLUSION

(i) electrical stimulation evokes'off' colon contractions, which can be coordinated to result in propulsion; (ii) the best combination for current and pulse duration to induce propulsive contractions is 15 mA and 3 ms; (iii) nitrergic and cholinergic pathways mediate responses to electrical stimulation.

Complete small-bowel transit in patients undergoing capsule endoscopy: determining factors and improvement with metoclopramide

BACKGROUND

Passage of the capsule endoscope to the colon occurs in only approximately three quarters of patients. This study assessed factors that might influence the completeness of small-bowel transit, including orally administered metoclopramide.

METHODS

Clinical and procedural parameters were recorded prospectively for 150 patients undergoing capsule endoscopy. Metoclopramide was not administered to the first 83 patients (Group 1) but was given orally (10 mg) to the subsequent 67 (Group 2).

RESULTS

Small-bowel transit was complete in 63 patients in Group 1 (76%). Gastric transit time was significantly longer when the capsule did not reach the colon than when it did (114.9 +/- 32.6 minutes vs. 26.6 +/- 2.9 minutes; p=0.007). Small-bowel transit time also was longer. The likelihood of complete small-bowel passage was not predicted by any clinical or procedural factor. In Group 2 (metoclopramide), the capsule reached the colon in 65 (97%) patients (OR 10.3: 95% CI[2.32, 93.55], p <0.001). This improvement was associated with a significant reduction in gastric transit time (47.9 +/- 9.0 minutes vs. 30.8 +/- 7.5 minutes; p=0.025).

CONCLUSIONS

Metoclopramide increases the likelihood of a complete small-bowel examination in patients undergoing capsule endoscopy.

Clinical response to gastric electrical stimulation in patients with postsurgical gastroparesis

BACKGROUND & AIMS

The aim of this study was to report the long-term clinical response to high-frequency gastric electrical stimulation (GES) in 16 patients with postsurgical gastroparesis who failed standard medical therapy.

METHODS

Clinical data collected at baseline and after 6 and 12 months of GES included (1) severity and frequency of 6 upper gastrointestinal (GI) symptoms by using a 5-point symptom interview questionnaire and total symptom score, (2) health-related quality of life including physical composite score and mental composite score, (3) 4-hour standardized gastric emptying of a solid meal by scintigraphy, and (4) nutritional status.

RESULTS

The severity and frequency of all 6 upper GI symptoms, total symptom score, physical composite score, and mental composite score were significantly improved after 6 months and sustained at 12 months ( P < .05). All patients had delayed gastric emptying at baseline. Gastric emptying was not significantly faster at 12 months, although 3 normalized. At implantation, 7 of 16 patients required nutritional support with a feeding jejunostomy tube; after GES, 4 were able to discontinue jejunal feeding. The mean number of hospitalization days was significantly reduced by a mean 25 days compared with the prior year. One patient had the device removed after 12 months because of infection around the pulse generator.

CONCLUSIONS

Long-term GES significantly improved upper GI symptoms, quality of life, the nutritional status, and hospitalization requirements of patients with postsurgical gastroparesis. Although vagal nerve damage or disruption was part of the underlying pathophysiology, GES therapy was still effective and is a potential treatment option for the long-term management of postsurgical gastroparesis. A controlled clinical trial of GES for PSG patients (who are refractory to medical therapy) is indicated given these encouraging results.

American Gastroenterological Association technical review on the diagnosis and treatment of gastroparesis

This literature review and the recommendations herein were prepared for the American Gastroenterological Association Clinical Practice Committee. The paper was approved by the Committee on May 16, 2004, and by the AGA Governing Board on September 23, 2004.

[Gastroparesis on a gastric ulcer]

INTRODUCTION

Gastroparesis is the failure of the stomach to empty because of decreased gastric motility. It's a fairly frequent medical problem. Diabetes is the most common known cause.

OBSERVATION

The first case report is that of an 82 year-old woman, in whom acute gastric distension occurred, evoking a gastric volvulus on the scan. Upper endoscopy revealed gastric ulcers. All symptoms disappeared with medical treatment. The second case report concerns a 37 year-old man who was admitted with signs of occlusion. CT scans revealed acute gastric distension. Emergency surgery revealed no gastric volvulus. Upper endoscopy revealed gastritis and numerous ulcers. The signs regressed with medical treatment.

DISCUSSION

Our observations are original in their -pseudo-surgical discovery. Acute gastric distension is rare, but must be recognised because of the risk of perforation and rupture of the stomach walls. These case reports are also original in their aetiology. Gastric ulcers are rarely described in this situation. CONCLUSION; Gastroparesis is a frequent situation but potentially severe. A review of the principle signs, aetiology and treatment is made.

Gastric pacing for severe gastroparesis in a heart-lung transplant recipient

Gastroparesis is a serious complication of lung and heart-lung transplantation that can lead to malnutrition, gastroesophageal reflux, aspiration pneumonia and deteriorating lung function. Some patients with severe gastroparesis have symptoms that are refractory to dietary modifications and gastric promotility agents and require surgery. We describe the successful use of gastric pacing for the management of intractable gastroparesis, malnutrition and recurrent aspiration in a heart-lung allograft recipient. Lung transplant recipients with severe gastroparesis may benefit from gastric pacing.

Clinical issues in the care of critically ill diabetic patients

Critically ill patients with a preexisting diagnosis of diabetes mellitus are very common and they have several inherent disorders that make their ICU care challenging. There is increasing evidence that hyperglycemia is all too common in the critically ill and that improved glucose control at presentation and during an ICU stay improves mortality. Glucose control after acute myocardial infarction and coronary artery bypass grafting in particular affects patient outcome and mortality. Diabetic patients are more prone to several medical problems that can predispose them to critical illness, prolong hospitalization, and increase mortality. Delayed gastric emptying and altered metabolism that affect medication dosing, absorption, and efficacy are common in this population. In addition, many patients with diabetes have renal dysfunction that can cause difficulties with drug excretion and glucose monitoring. Finally, patients with diabetes have an increased rate and severity of life-threatening infections and venous thromboembolism than do patients with normal glucose metabolism. There are many treatment options for patients with diabetes, and hyperglycemia in the ICU should be corrected in order to avoid adverse outcomes.

Gastroparesis following kidney/pancreas transplant

This pilot study examined associations among patterns of gastric myoelectrical activity, symptoms of gastroparesis, years of diabetes, months of dialysis, and use of gastrointestinal medications in gastroparetic kidney-pancreas (KP) transplant recipients. Electrogastrography (EGG) and gastric symptom data were obtained from 42 transplant recipients before and after transplant (6, 12, and 24 months). Recipients were 38 +/- 7 yr of age, 88% Whites, and 60% male; 97% had hypertension. All had functioning grafts post-transplant (mean creatinine, 1.59 +/- 0.66 mg/dL, and serum glucose 91.97 +/- 24.92 mg/dL). Sixteen subjects had normal EGG (2.7-3.2 cycles per minute, cpm); two were tachygastric (>3.2 cpm) at all time points; one remained bradygastric (<2.7 cpm) throughout the study period. Following transplant, symptoms lessened and were associated with 6-month normalization of EGG (r = 0.41, p = 0.02). A small change in the percentage of patients with normal EGG was observed from baseline to 24 months (67% vs. 69% respectively); however, there was a shift from bradygastria (29% to 15% respectively) to tachygastria (5% to 15% respectively). Prescribed prokinetic and antisecretory medications use increased over the study period from 13 (31%) subjects at baseline to 32 (86%) at 6 months; 21 (78%) at 12 months; and 12 (92%) at 24 months. Although symptoms diminish following transplant, gastroparesis remains a significant problem for transplant patients. Normalization of EGG and shifts from bradygastria to tachygastria occur post-transplant. Our results suggest that serial EGGs and frequent assessment of symptoms can be used to follow gastroparesis in KP recipients.

Erythromycin in the short- and long-term control of dyspepsia symptoms in patients with gastroparesis

BACKGROUND

Few prokinetic drugs are available to treat gastroparesis. Data are limited on short-term and long-term efficacy of erythromycin as a prokinetic drug.

GOALS

Assess efficacy of low-dose erythromycin suspension to treat gastroparesis.

STUDY

Patients with dyspepsia and gastroparesis by gastric emptying study were treated with low-bulk diet and low-dose (50-100 mg 3 times a day and at bedtime) oral erythromycin suspension. Data were collected by retrospective chart review and telephone questionnaire for short- and long-term follow-up, respectively.

RESULTS

Of 25 patients, 18 had short-term follow-up, 18 had longterm follow-up, and 14 had both. On short-term follow-up, 15 patients (83%) experienced some or dramatic improvement, while 3 (17%) experienced worsening or no change in symptoms (P = 0.005). Mean duration of long-term use was 11 +/- 7 months. On long-term followup, 12 (67%) patients noticed some or dramatic improvement, while 6 (33%) experienced worsening or no change in symptoms (P = 0.16). Correlation (0.7) between short- and long-term response was significant (P < 0.005). Of the 3 patients with poor short-term response, none did well long term. Of the 11 patients with some or dramatic response in short-term, 7 continued to have some response long term. There was no relation between gastric emptying time and response to erythromycin suspension.

CONCLUSIONS

Treatment of gastroparesis with low-dose erythromycin and low-bulk diet results in a dramatic short-term improvement in the majority of patients. Short-term response predicts long-term response. This response may not be as great, possibly due to tachyphylaxis.

Current concepts in diabetic gastroparesis

Diabetic gastroparesis is a common and debilitating condition affecting millions of patients with diabetes mellitus worldwide. Although gastroparesis in diabetes has been known clinically for more than 50 years, treatment options remain very limited. Until recently, the scientific literature has offered few clues regarding the precise aetiology of gastric dysfunction in diabetes.Up to 50% of patients with diabetes may experience postprandial abdominal pain, nausea, vomiting and bloating secondary to gastric dysfunction. There is no clear association between length of disease and the onset of delayed gastric emptying. Gastroparesis affects both type 1 (insulin dependent) and type 2 (non- insulin dependent) forms of diabetes. Diagnosis requires identifying the proper symptom complex, while excluding other entities (peptic ulcer disease, rheumatological diseases, medication effects). The diagnosis of gastroparesis may be confirmed by demonstrating gastric emptying delay during a 4-hour scintigraphic study. Treatment options are limited and rely on dietary modifications, judicious use of available pharmacological agents, and occasionally surgical or endoscopic placement of gastrostomies or jejunostomies. Gastric pacing offers promise for patients with medically refractory gastroparesis but awaits further investigation. Current pharmacological agents for treating gastroparesis include metoclopramide, erythromycin, cisapride (only available via a company-sponsored programme) and domperidone (not US FDA approved). All of these drugs act as promotility agents that increase the number or the intensity of gastric contractions. These medications are not uniformly effective and all have adverse effects that limit their use. Cisapride has been removed from the open market as a result of over 200 reported cases of cardiac toxicity attributed to its use. Unfortunately, there is a paucity of clinical studies that clearly define the efficacy of these agents in diabetic gastroparesis and there are no studies that compare these drugs to each other. The molecular pathophysiology of diabetic gastroparesis is unknown, limiting the development of rational therapies. New studies, primarily in animals, point to a defect in the enteric nervous system as a major molecular cause of abnormal gastric motility in diabetes. This defect is characterised by a loss of nitric oxide signals from nerves to muscles in the gut resulting in delayed gastric emptying. Novel therapies designed to augment nitric oxide signalling are being studied.

A systematic review of surgical therapy for gastroparesis

Gastroparesis is characterized by delayed gastric emptying in the absence of obstruction. Common symptoms include nausea, vomiting, and abdominal pain. Severe gastroparesis might result in recurrent hospitalizations, malnutrition, and significant mortality. Patients failing medical therapy are often considered for a variety of surgical interventions, the efficacy of which is not well studied. This review summarizes available literature on surgical interventions in gastroparesis. A MEDLINE search for the period from 1966 to 2002 was performed to identify all English language literature regarding surgical interventions in gastroparesis. Therapies reviewed were gastrostomy, jejunostomy, gastric pacing/stimulation, and gastrectomy or surgical drainage procedures. Candidate studies involved human subjects and included surgical series or trials. The search was conducted independently by two authors and discrepancies resolved by consensus opinion. Seventeen articles met inclusion criteria. These included series reporting on gastrostomy (2), jejunostomy (3), gastric stimulation (2), and gastrectomy for postsurgical (6), diabetic (3), and idiopathic (1) gastroparesis. All trials were unblinded, uncontrolled case series or retrospective reviews. Methodologic differences did not allow for pooled analysis. Completion gastrectomy seems to provide symptom relief in postsurgical gastroparesis. Benefits of gastric surgery for other forms of gastroparesis are not adequately studied. Gastrostomy might provide symptom improvement, but only 26 subjects in two trials were evaluable. Jejunostomy improved symptoms and nutrition in 32 evaluable subjects in three trials but had significant complications. Gastric neurostimulation improves symptoms of nausea and vomiting, but therapeutic gain beyond placebo has not been demonstrated. Limited data exist concerning surgical therapies of gastroparesis. Completion gastrectomy seems effective for postsurgical gastroparesis, but a cautious approach is warranted before surgical therapies in diabetic or idiopathic gastroparesis are used.