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New Technology

Electrostimulation for Intractable Delayed Emptying of Intrathoracic Stomach After Esophagectomy

^a Department of Surgery, University of Mississippi Medical Center, Jackson, Mississippi
^b Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi

Accepted for publication September 18, 2007.

^_* Address correspondence Dr Salameh, 2500 North State St, Jackson, MS 39216 (Email: jsalameh{at}laparo-surgery.com).

Dr Abell discloses that he has a financial relationship with Medtronic.

 

	Abstract

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Purpose: The use of the denervated intrathoracic stomach as esophageal substitute can rarely lead to severe delayed gastric emptying. We describe the use of electrostimulation for this condition.

Description: Gastric electrical stimulation (GES) is used to treat medically refractory gastroparesis and uses a battery powered neurostimulator connected to the gastric antrum with two electrodes. We implant the electrodes through a right thoracotomy and tunnel them to the right subcostal area where the pacemaker is placed.

Evaluation: Medically refractory gastroparesis developed in 2 male patients, aged 52 and 60 years, who underwent Ivor-Lewis esophagectomies for esophageal adenocarcinoma and were dependant on jejunostomy feedings. These patients initially had endoscopic placement of temporary stimulating electrodes with significant improvement in symptoms and radionucleotide gastric emptying. The patients subsequently underwent implantation of a permanent GES device. Relief of symptoms was persistent with no nausea or vomiting and a decrease of total symptom score (maximum 20) from 12.5 and 16 to 6 and 9, respectively.

Conclusions: Patients with intractable delayed gastric emptying after esophagogastrectomy may benefit from a GES device implanted through a thoracotomy.

The use of the denervated intrathoracic stomach as an esophageal substitute can lead to delayed gastric emptying in approximately 50% of patients immediately after esophagectomy [1]. In addition, dumping syndrome, reflux, and dysphagia may contribute to abnormal gastrointestinal function. It is common for patients to loose up to 15% of their body weight from the time of diagnosis through the first postoperative 6 months [2]. Fortunately, the intrathoracic gastric emptying significantly improves over time and the weight loss trend levels off after 6 months. However, few patients suffer from persistent severe gastroparesis resulting in nutritional deficiency and poor quality of life. This condition can be difficult to treat and is often refractory to medical therapy.

	Technology

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Gastric electrical stimulation (GES) received the Food and Drug Administration’s Humanitarian Use Device approval in 2000 and has been shown to be an effective treatment alternative in patients with medically refractory diabetic or idiopathic gastroparesis [3]. It has also been used off-label in postsurgical or surgery-associated gastroparesis with significant clinical improvements at long term follow-up [4]. The GES has not been previously used for severe refractory delayed emptying of the intrathoracic stomach after Ivor-Lewis esophagogastrectomy. In this study, we describe and evaluate the role of electric stimulation therapy in patients with this condition.

	Technique

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Gastric electrical stimulation uses low-energy stimuli administered at a frequency higher than the intrinsic slow-wave frequency of the normal stomach. It consists of a battery powered neurostimulator (Medtronic ITREL 3, Model 7425G or Enterra [Medtronic, Minneapolis, MN]), it is connected to the gastric antrum with two stimulating electrodes (Medtronic Model 4351 or 4300 [Medtronic]), and it is inserted into the muscularis propria 1 cm apart and 10 cm proximal to the pylorus (Fig 1). Normally the pacemaker is implanted using a laparoscopy or laparotomy. For gastroparesis after esophagogastrectomy, the intrathoracic stomach is exposed using a right thoracotomy approach, and the leads are implanted in the gastric conduit 10 cm proximal to the pylorus, which usually lies just distal to the esophageal hiatus (Fig 1). Intraoperative endoscopy is used to verify the position of the pylorus to make sure that the electrodes placed in the stomach wall have not penetrated the mucosa. The leads are then tunneled through the costophrenic angle to a subcutaneous pocket created in the right subcostal area where the pacemaker is placed (Fig 1). The impedance is measured and verified to be between 200 to 800 ohm. The neurostimulator is programmed using a standard output current of 5 mA, a voltage determined based on the impedance, a rate of 14 Hz, a pulse width of 330 microseconds, and a cycling mode of on for 0.1 second and off for 5.0 seconds. The neurostimulator is then turned on.

View larger version (29K): [in this window] [in a new window]   Fig 1. Illustration of the gastric conduit with the two stimulating electrodes implanted and connected to the pacemaker in the right upper quadrant. Inset: electrode placed into the muscularis propria and secured to a disk.

	Clinical Experience

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All GES systems were implanted after Institutional Review Board (IRB) approval using the guidelines for approval of a humanitarian device exemption. Individual informed consents for the GES procedures were obtained. Individual consent for the study was waived.

Symptoms of gastroparesis were assessed at baseline and at all stages of treatment and follow-up using a symptom score that has been previously described and is used in multicenter studies [3]. Nausea, vomiting, bloating and distension, early satiety and abdominal pain were each scored on a scale from 0 to 4 based on severity, with 0 being no symptom and 4 being the most severe symptom. The sum of all five symptom scores constitutes the total symptom score (TSS), 20 being the highest and worst possible score. The neurostimulator is readjusted to different therapy settings during follow-up visits, if dictated by the symptom scores.

Evaluation
Two male patients, 52 and 60 years old, who had previously undergone an Ivor-Lewis esophago-gastrectomy for distal esophageal adenocarcinoma, were referred to us for refractory gastroparesis. Chronic nausea and vomiting, along with anorexia, early satiety, bloating and epigastric pain developed in both patients soon after the surgery. One of the patients who had not had a drainage procedure at the time of the initial surgery underwent a laparotomy for pyloroplasty 2 months after the surgery without relief of his symptoms. Patients did not respond to various prokinetic agents including erythromycin and metoclopramide. They both were dependant on enteral feeding through a jejunostomy to maintain their weight.

On presentation to us, total symptom scores were 12.5 and 16 (maximum 20). On imaging, including upper gastrointestinal contrast study and computed tomographic scan, the gastric conduit appeared dilated without evidence of mechanical obstruction. The size of the gastric tube at the time of the initial esophagogastrectomy operation could not be objectively assessed from the records of the patients. Radionucleotide gastric emptying studies showed 25% and 51% gastric retention at 4 hours in both patients, respectively.

Both patients initially had placement of temporary GES electrodes endoscopically with rapid significant improvement in their nausea score (0 and 0 out of 4), vomiting score (0 and 0 out of 4), and total symptom score (5 and 7 out of 20). Radionucleotide gastric emptying also improved significantly with temporary electrostimulation to 19% and 8% at 4 hours, respectively.

Patients subsequently underwent implantation of a permanent GES device as just described. Postoperative courses were unremarkable. Both patients experienced significant and persistent postoperative relief of symptoms. Nausea and vomiting mostly resolved in both patients and the total symptom score improved to 6 and 9 at a follow-up of 4 and 15 months, respectively.

	Comment

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Subsequent to esophagectomy and reconstruction with gastric pull-up, the intrathoracic vagally denervated the stomach, initially believed to act primarily as a passive conduit, now seemed to recover more and more motor activity over time, and may have even generated complete migrating motor complexes [6]. This motor activity seemed to return to normal in a progression from the pylorus cephalad [7]. Intrathoracic gastric emptying, as evaluated by radioisotope, also increased significantly over time [1]. Even though the patients will never eat the way they did before their surgery, most of them will ultimately be able to tolerate smaller, more frequent meals and maintain their weight.

Some patients do not improve their gastric emptying and remain significantly symptomatic. Their complaints seem to correlate with the myoelectric and contractile activities of the transposed stomach. They have a higher occurrence of tachygastria on electrogastrography and a decreased postprandial contractile activity on manometry [8]. In these patients with persistent gastroparesis, prokinetic agents should be attempted as first line of therapy. Erythromycin has been shown to significantly improve gastric emptying of the gastric conduit by stimulating gastric motility [7, 9, 10]. In the rare cases in which gastroparesis is refractory to prokinetics, patients have no other treatment options and suffer from poor quality of life due to persistent, hard to control symptoms, mainly nausea and postprandial vomiting. They almost exclusively rely on enteral feedings through a jejunostomy for their nutrition.

Although GES therapy is an approved technique for patients with idiopathic and diabetic gastroparesis, we have previously expanded its use to postsurgical gastroparesis, including patients with various gastrectomy procedures and vagotomy. In our first 6 patients with refractory postoperative gastric surgery gastroparesis, who were implanted with gastric pacemakers, significant improvements were seen in symptoms, health-related quality of life, and solid and liquid gastric emptying at long-term follow-up [4]. Our current experience with electrostimulation in intractable delayed emptying of the vagally denervated intrathoracic stomach after esophagectomy seems promising. It provides an attractive treatment option for this difficult group of patients unresponsive to conventional medical therapy, who may have otherwise had no other alternative. Implanting these pacemakers does require a right thoracotomy, although thoracoscopy may be used, especially after transhiatal esophagectomy. Before embarking in these major operations, the response to electrostimulation must first be assessed by temporary endoscopic pacing, which has been shown to be safe and effective with outcomes that correlate well with those of permanent GES [5]. In the future, if our results are further confirmed by larger studies, it may be attractive to prophylactically implant permanent electrodes at the time of esophagogastrectomy, leaving them subcutaneously accessible for later use, as necessary, thus circumventing a second thoracotomy in a potentially debilitated individual.

In conclusion, the symptoms of patients with intractable delayed gastric emptying after Ivor-Lewis esophagectomy can be significantly improved with electrostimulation. Implantation of the gastric pacemaker in these cases requires a thoracotomy.

	Disclosures and Freedom of Investigation

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The authors state that there were no industry funds used to perform the evaluation of the technology. The tested technology was purchased by the patient or covered by his insurance. The authors had full control of the design of the study, methods used, outcome measurements, analysis of data, and production of the written report.

	Footnotes

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^Disclaimer The Society of Thoracic Surgeons, the Southern Thoracic Surgical Association, and The Annals of Thoracic Surgery neither endorse nor discourage use of the new technology described in this article.

	References

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1. Lee HS, Kim MS, Lee JM, Kim SK, Kang KW, Zo JI. Intrathoracic gastric emptying of solid food after esophagectomy for esophageal cancer Ann Thorac Surg 2005;80:443-447.[Abstract/Free Full Text]
2. Donington JS. Functional conduit disorders after esophagectomy Thorac Surg Clin 2006;16:53-62.[Medline]
3. Abell TL, Van Cutsem E, Abrahamsson H, et al. Gastric electrical stimulation in intractable symptomatic gastroparesis Digestion 2002;66:204-212.[Medline]
4. Oubre B, Luo J, Al-Juburi A, Voeller G, Familoni B, Abell TL. Pilot study on gastric electrical stimulation on surgery-associated gastroparesis: long-term outcome South Med J 2005;98:693-697.[Medline]
5. Ayinala S, Batista O, Goyal A, et al. Temporary gastric electrical stimulation with orally or PEG-placed electrodes in patients with drug refractory gastroparesis Gastrointest Endosc 2005;61:455-461.[Medline]
6. Collard JM, Romagnoli R, Otte JB, Kestens PJ. The denervated stomach as an esophageal substitute is a contractile organ Ann Surg 1998;227:33-39.[Medline]
7. Nakabayashi T, Mochiki E, Garcia M, et al. Gastropyloric motor activity and the effects of erythromycin given orally after esophagectomy Am J Surg 2002;183:317-323.[Medline]
8. Izbeki F, Wittmann T, Odor S, Botos B, Altorjay A. Synchronous electrogastrographic and manometric study of the stomach as an esophageal substitute World J Gastroenterol 2005;11:1172-1178.[Medline]
9. Narasimhan R, Mittal BR, Gupta NM. Effect of erythromycin and cisapride on emptying of the vagally denervated intrathoracic stomach Trop Gastroenterol 2002;23:122-124.[Medline]
10. Burt M, Scott A, Williard WC, et al. Erythromycin stimulates gastric emptying after esophagectomy with gastric replacement: a randomized clinical trial J Thorac Cardiovasc Surg 1996;111:649-654.[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Giorgio M. Aru William Bolton Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Salameh, J. R. Articles by Abell, T. L. Search for Related Content PubMed PubMed Citation Articles by Salameh, J. R. Articles by Abell, T. L. Related Collections Esophagus - other Related Article