An otherwise healthy 11-year old boy is diagnosed with severe gastroparesis manifested by nausea, vomiting, and weight loss. He has been unresponsive to dietary changes, medications and gastric electrical stimulation. His workup included an upper endoscopy and upper GI series that did not show anatomic narrowing of the gastric outlet. Which of the following surgical options would be considered most appropriate for his condition?

 

a Intrapyloric botox injection

 

b Permanent gastric electrical stimulation

 

c Operative pyloroplasty

 

d Gastrojejunostomy

 

e Partial gastrectomy

C

D

D

correct answer

a Intrapyloric botox injection

 

The two main etiologic domains for failure of gastric function are gastroparesis (muscular, neurologic, or both) and anatomic gastric outlet obstruction. The most common causes of gastroparesis are idiopathic, post-viral, diabetes, neurologic disorders, medications, eating disorders, and connective tissue disorders. Causes of anatomic gastric outlet obstruction include peptic ulcer disease, antral web, foreign body ingestion, congenital malformations, Crohns disease, caustic ingestion, or post-surgical complications.

 

When a child presents with signs or symptoms of gastric dysfunction, a thorough workup is crucial to identify the underlying cause of gastroparesis, gastric outlet obstruction, or both. A detailed history includes symptoms, eating habits, medical history, medications, and relevant events like recent illnesses. Blood work should include electrolytes, glucose, thyroid function, and workup for infection or inflammation. Imaging includes upper GI series, ultrasound, upper endoscopy, CT scan, and gastric emptying study. In adults, endoFLIP may be very useful.

 

Endoscopic functional luminal imaging probe (endoFLIP) is a device that uses 16 sensors inside a balloon to assess the physiologic characteristics of a sphincter. The balloon is inflated inside the sphincter to measure the cross sectional diameter and distensibility of the pylorus. EndoFLIP is also used to help diagnose achalasia.

 

A 2019 review of the literature of children with gastroparesis emphasizes individualization of therapy based on diagnostic findings and symptomatology, Primary interventions include dietary modifications, prokinetic drugs, and post pyloric feedings. For children who fail these therapies and who have more significant symptoms, intrapyloric botulinum injection with or without pyloric dilation is one of the next recommended treatment. Post pyloric feedings or parenteral nutrition may also be considered.

 

As this patient did not respond to temporary gastric stimulation, he should not undergo permanent gastric pacing. Interestingly, in adults with gastroparesis, intrapyloric botulinum toxin injection was not recommended by the 2022 published American College of Gastroenterology guidelines for gastroparesis, favoring pyloroplasty instead. Even more recent data show promising results regarding the equivalence of operative pyloroplasty and gastric per-oral endoscopic myotomy (G-POEM) in adults. The experience for G-POEM in children is still nascent but bears watching.

 

Gastrojejunostomy and gastrectomy are invasive procedures that are reserved for severe, rare cases that are refractory to other modalities.