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