Surgical management of severe refractory gastroparesis: outcomes of jejunostomy tube placement

Abstract

Background: Surgical referrals for refractory gastroparesis (GP) are becoming more common as medical options are limited. Supplemental intestinal alimentation via feeding jejunostomy tubes (JT) is required to treat underlying malnutrition in only the most severe cases. The aim of this study was to determine predictive factors associated with successful restoration of oral nutrition after insertion of a JT for patients with severe malnutrition associated with GP.

Methods: Retrospective review of all patients who had JT inserted between November 2007 and October 2023 at The Oregon Clinic for severe gastroparesis. Baseline demographics, comorbidities, objective studies, symptom scores and operative details were recorded. The primary outcome was successful return to independent oral intake defined as removal of the feeding tube without additional supplementation (TPN) at one year after the last procedure.

Results: One hundred and eleven of 905 patients (12%) had JTs inserted during the study period. There was a total of 164 gastroparesis procedures including pyloric intervention (81), gastric neurostimulator (GNS) implantation (29), RNY gastrectomy (19), and fundoplication (35). Multiple procedures were performed in 48% during the disease course. Twenty-six (23.4%) patients achieved adequate return of oral intake and successful JT removal by 12 months, while (62%) required ongoing feeding access and/or TPN. Only pyloric intervention was independently associated with successful JT removal at one year (p = 0.011, OR 5.032, p = 0.045). Patients undergoing two procedures had the highest rate of JT removal within one year (36.6%, p = 0.036, OR 12.00, p = 0.022).

Conclusion: Malnutrition requiring feeding jejunostomy tubes is a rare complication of gastroparesis. When the disease has progressed to this stage, most patients remain j-tube dependent long-term despite surgical interventions. Pyloric intervention (laparoscopic pyloroplasty or endoscopic pyloromyotomy) substantially increases the likelihood of successful resumption of oral alimentation and subsequent liberation from feeding tubes. Pyloric intervention should be performed concurrently for any patient requiring a feeding jejunostomy for severe gastroparesis.

Keywords: Endoscopic pyloromyotomy; Gastroparesis; Jejunostomy tube; Pyloric intervention; Pyloroplasty; Refractory gastroparesis.