Laparoscopic Placement of Gastric Electro Stimulator
Performed by Jody Johnson, M.D.Presentation by Jonathan Powell, M1
Female Type 1 diabetes has lead to peripheral
neuropathy◦ Resulted in gastroparesis
Peripheral neuropathy: In this case the patient has diabetic peripheral neuropathy in which the high blood sugar levels damaged her peripheral nerves◦ Can cause pain (or sometimes lack of sensation) and loss
of motor control
Patient Hx
A stomach disorder in which a full thickness loss of cells of Cajal (neuroconducting cells of the stomach) leads to a decrease in gastric emptying
Stomach muscles function poorly◦ Food digested slowly, results in a lot of pain
Common causes: ◦ Idiopathic in most cases◦ Type 1 or 2 diabetes
Gastroparesis
Proper nutrition/diet changes: restrict fats, frequent but small meals, lots of fluids
Drugs: ◦ Prokinetic: improve rate of stomach emptying ex.
Methylnaltrexone◦ Antiemetic: control nausea and vomiting, no effect of
stomach emptying ex. Prochlorperazine Surgery: the last resort
◦ Pyroplasty: widening of pyloric valve◦ Gastric ESTIM
Treatment of Gastroparesis
Enterra neurostimulator implanted beneath the skin
Anode and cathode implanted in wall of stomach along the Greater Curvature
Handheld programming device is used to alter the degree and frequency of stimulation (catered to each patient)
Effectiveness has not been demonstrated
Gastric ESTIM: General Principles
Preparation
Patient Position Equipment Used
Scissors Marilyn dissector O-suture 3-O silk R01 Suture Debakey Enterra neurostimulator Two trochars (size 5) One trochar (size 10) Laparoscope Hand held programming
device to set frequency and degree of current discharge by the device
Patient Position
Initial incisions: one midline incision between abdominal quadrants one and two for placement of scope
Two lateral incisions for size 5 trochars (5s are free)◦ One in each abdominal
quadrant
Procedure
ID the pylorus Deflate stomach Mark point 10cm
along Greater Curve of Stomach starting from pylorus
Insert leads into stomach wall◦ Caudal lead at 9.5cm
from pylorus◦ Rostral lead at 10.5 cm
from pylorus
Procedure
Make pocket at Left mid-quadrant for subcutaneous placement of battery
Externalize leads Close up Interrogation: device
that, when placed above ESTIM site, can be used to measure battery life and set the current released during each discharge of the device
Procedure
Patient can be sent home that day Possible complications:
◦ Pain, lack of healing, or infection where device was implanted
◦ Parts of device could wear through skin◦ Allergic rxn to device◦ Leads may perforate your stomach or device components
may become entangled with or obstruct other internal organs
◦ Tissue damage from improper stimulation setting or malfunction
Post Op Care/Complications
Gastric ESTIM is no longer being performed because the effectiveness of this procedure could not be demonstrated
Currently, ESTIM procedures are used for maladies such as:◦ Xerostomia- dry mouth due to lack of saliva
Intraoral electrostimulation device increases salivary output of Parotid Gland
◦ Function electrical stimulation- use electrical stimulation to activate peripheral nerves affected by paralysis from spinal cord injury, head injury, stroke, etc Sometimes referred to as neuromuscular electrical stimulation
ESTIM today
Buckles, MD, Daniel, Jameson Forster, MD, and Richard McCallum, MD. "The Treatment of Gastroparesis in the Age of the Gastric Pacemaker: A Review." Medscape 5.4 (2003): 6. Web. 15 Apr 2011. <http://www.medscape.com/viewarticle/460632>.
"About Gastroparesis." Medtronic. Medtronic Inc., 22 09 2010. Web. 15 Apr 2011. <http://www.medtronic.com/your-health/gastroparesis/index.htm>.
McCallum, MD, Richard, William Snape, MD, Fredrick Brody, MD, and John Wo, MD. "Gastric Electrical Stimulation With Enterra Therapy Improves Symptoms From Diabetic Gastroparesis in a Prospective Study." Clinical Gastroenterology andHepatology 8.11 (2010): 947-954.e1. Web. 15 Apr 2011. <http://www.cghjournal.org/article/s1542-3565(10)00545-8/abstract>.
Douglas, David. "Electrostimulation Relieves Xerostomia." Medscape News (2010): n. pag. Web. 15 Apr 2011.< http://www.medscape.com/viewarticle/731503>.
Abell, MD, Thomas. "Gastric Electrical Stimulation for Medically Refractory Gastroparesis." University of California San Francisco. University of California San Francisco College of Medicine, 2003. Web. 15 Apr 2011. <http://sadieo.ucsf.edu/course/old/Abell1.pdf>.
References