1. Laparoscopic Placement of Gastric Electro Stimulator
Performed by Jody Johnson, M.D.
Presentation by Jonathan Powell, M1

2. Patient Hx 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

3. Gastroparesis
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

4. Treatment of 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

5. Gastric ESTIM: General Principles
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

6. 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
Equipment Used

7. Patient Position

8. Procedure
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

9. 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

10. 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

11. Post Op Care/Complications
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

12. ESTIM today
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

13. References
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 <
"About Gastroparesis." Medtronic. Medtronic Inc., Web. 15 Apr <
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): e1. Web. 15 Apr < 8/abstract>.
Douglas, David. "Electrostimulation Relieves Xerostomia." Medscape News (2010): n. pag. Web. 15 Apr 2011.<
Abell, MD, Thomas. "Gastric Electrical Stimulation for Medically Refractory Gastroparesis." University of California San Francisco. University of California San Francisco College of Medicine, Web. 15 Apr <