Laparoscopic revision of gastric pacing wires

Medical and surgical management of gastroparesis: a systematic review

BACKGROUND

Gastroparesis (GPS) is a rare disease with multiple etiologies that results in delayed gastric emptying. Diagnosis of GPS can be challenging due to its rather complex clinical presentation. Pharmacologic refractory cases require surgical interventions, all of which have yet to be standardized and characterized.

OBJECTIVES

We present a review of the literature and provide an update of current therapies for patients with GPS.

SETTING

Department of General Surgery, Academic Hospital, United States.

METHODS

We conducted a comprehensive search in PubMed, Google Scholar, and Embase of English-written articles published in the last 38 years, with an advance title search of "gastroparesis management." Other keywords included: "surgical management" and "refractory gastroparesis." Further references were obtained through cross-reference.

RESULTS

A total of 12,250 articles were selected after eliminating duplicates. Following thorough screening of selection criteria, 68 full-text articles were included for review.

CONCLUSION

GPS is a challenging disease to manage. Nutritional support must remain the primary approach, followed by either medical or surgical treatment modalities if necessary. In patients with refractory gastroparesis, adjunctive therapies have been proposed as promising long-term options.

Gastric Electrical Stimulation for Gastroparesis and Chronic Unexplained Nausea and Vomiting

OPINION STATEMENT

Gastroparesis is a heterogeneous clinical syndrome. Some patients have debilitating vomiting, weight loss, and dehydration, while others have effortless regurgitation of undigested foods or postprandial distress suggestive of functional dyspepsia. Gastric electrical stimulation (GES) has been proposed as an effective treatment option for patients with gastroparesis refractory to medical therapy. Evidence suggests that the clinically available device, a low-energy high-frequency GES, activates the vagal afferent pathways to influence the central control mechanisms for nausea and vomiting. Myoelectrical effects of the stomach are also involved. The results of randomized controlled trials (RCTs) for adults with diabetic and idiopathic gastroparesis are conflicting. There are no RCTs in adults with chronic unexplained nausea and vomiting (CUNV) with normal gastric emptying or in children with gastroparesis. However, there is increasing evidence from large unblinded studies showing the long-term efficacy in selected adults with gastroparesis. Selection criteria should be based on three categories: (a) underlying etiology, (b) clinical presentation and predominant symptoms, and (c) potential risk for complication. Significant abdominal pain, daily opiate use, and idiopathic gastroparesis are identified as negative predictors of success. Temporary GES has been utilized to identify patients who may benefit from surgical GES, but this strategy has yet to be proven in controlled studies. Objectives for this review are to highlight the mechanisms of action for GES, to look at the evidence for clinical efficacy, and to select patients who are likely to benefit.

Gastric electrical stimulation for gastroparesis: a goal greatly pursued, but not yet attained

The lack of an effective medical treatment for gastroparesis has pushed the research of new techniques of gastric electrical stimulation (GES) for nearly half a century of experimentation with a large variety of electrical stimuli delivered to the gastric wall of animals and patients with gastroparesis. Three principal methods are currently available: gastric low-frequency/high-energy GES with long pulse stimulation, high-frequency/low-energy GES with short pulse stimulation and neural sequential GES. The first method aims to reset a regular slow wave rhythm, but has variable effects on contractions and requires devices with large and heavy batteries unsuitable for implantation. High-frequency/low-energy GES, although inadequate to restore a normal gastric electro-mechanical activity, improves dyspeptic symptoms, such as nausea and vomiting, giving patients a better quality of life together with a more satisfactory nutritional status and is suitable for implantation. Unfortunately, the numerous clinical studies using this type of GES, with the exception of two, were not controlled and there is a need for definitive verification of the effectiveness of this technique to justify the cost and the risks of this procedure. The last method, which is neural sequential GES, consists of a microprocessor-controlled sequential activation of a series of annular electrodes along the distal two thirds of the stomach and is able to induce propagated contractions causing forceful emptying of the gastric content. The latter method is the most promising, but has been used only in animals and needs to be tested in patients with gastroparesis before it is regarded as a solution for this disease.

Feasibility of gastric electrical stimulation by use of endoscopically placed electrodes

BACKGROUND

Gastric electrical stimulation (GES), which has been reported to have therapeutic potentials for gastroparesis and obesity, involves the surgical placement of electrodes with the patient under general anesthesia. New methods are needed for implanting GES electrodes in a safer and more feasible way.

OBJECTIVE

Our purpose was to investigate the safety and feasibility of placing electrodes endoscopically for GES.

DESIGN AND SETTING

A pilot study.

SUBJECTS

Six female hound dogs that weighed 13 to 22 kg.

INTERVENTIONS

Endoscopically placed electrodes passed through the abdomen and the stomach wall.

MAIN OUTCOME MEASUREMENTS

The study was performed in dogs surgically implanted with gastric serosal electrodes and endoscopically implanted electrodes. The experiment consisted of a 30-minute baseline, a 30-minute GES, and a 30-minute recovery. GES was performed through endoscopically placed electrodes. Gastric slow waves were simultaneously recorded with the serosal electrodes and the endoscopically placed electrodes.

RESULTS

(1) The slow wave frequency recorded from the endoscopically placed electrodes was significantly correlated with that from the serosal electrodes (r = 0.97, P < .002). (2) GES through the endoscopically placed electrodes was able to entrain gastric slow waves. (3) No gastric leakage into the abdominal cavity was noted and the dogs were healthy and comfortable. (4) The endoscopically placed electrodes remained for 2 to 3 weeks.

LIMITATIONS

The fixation of the electrodes needs to be improved for longer-term uses.

CONCLUSIONS

GES may be accomplished without surgery by inserting the electrode wire through the abdomen under endoscopy. The study results indicate that the endoscopically placed electrodes are effective for GES and do not result in any adverse events.

Laparoscopic Insertion of Gastric Electrodes for Electrical Stimulation

Gastric electrical stimulation can provide symptomatic relief for patients with refractory gastroparesis. Traditionally, these wires are placed through a midline laparotomy. This paper describes and illustrates, in detail, the laparoscopic technique for successful implantation. Thirty-one consecutive patients from October 2003 to March 2005 underwent laparoscopic insertion of gastric stimulating wires for gastroparesis. Twenty-six patients were female. Four laparoscopic ports were used to insert a pair of electrodes. Anterior, cephalad retraction of the gastric wall is critical for accurate seromuscular placement of gastric leads. Intraoperative endoscopy was used to verify the seromuscular placement of the leads. Both leads were secured to a subcutaneous generator and electrical parameters were immediately established in the operating room. Patient demographics, operative details, and postoperative morbidities were recorded. All procedures were completed laparoscopically. The mean operative time was 114.4 +/- 20.9 minutes (range, 95-140). No perioperative mortality occurred. Two patients developed cellulitis at the generator site postoperatively and oral antibiotics were prescribed for one week postoperatively. No hardware was removed. Two patients had their generators repositioned due to pain at the pocket site. Gastric electrical stimulation is a novel treatment modality for patients with refractory gastroparesis and can be accomplished safely via laparoscopy. Laparoscopic insertion is successful even in patients with prior surgery and intact gastrointestinal tubes. Long-term follow-up and the current prospective multicenter trial continue to assess the efficacy of this treatment modality.