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New Technology

Invited Commentary

22 River Reach Way, Charleston, SC 29407-3372

(Email: jrubin{at}knology.net).

Disruption of the gastrointestinal autonomic nervous system after esophagogastrectomy causes myriad difficulties that affect recovery and lifestyle. Atony of the gastric remnant transposed to the chest is a vexing and an all too common problem. The aperistaltic, distended gastric remnant becomes a reservoir of fluid and electrolyte loss, bacterial growth, and a source of pulmonary aspiration. If that is not enough, dumping syndrome and disorders of intestinal motility may follow on the heels of early woes caused by a paralyzed residual stomach.

In 1998, McCallum and colleagues [1] used multiple pairs of cardiac pacing wires affixed to the serosa of the stomach in 9 patients suffering from gastroparesis. They concluded that gastric pacing improved symptoms of gastroparesis and accelerated gastric emptying in patients with gastroparesis. Gastric electrical stimulation (GES) received the Food and Drug Administration’s Humanitarian Use Device approval for use in medically refractory gastroparesis in 2000. In 2002, the senior author’s successful multicenter study of 33 patients concluded that GES offers a safe and effective alternative for patients with intractable, symptomatic gastroparesis [2, 3].

The authors have now tested GES in the setting of medically refractory gastroparesis after Ivor Lewis esophagogastrectomy. The use of GES had already demonstrated significant and persistent improvements in symptoms, health-related quality of life, and solid and liquid gastric emptying at long-term follow-up in gastroparesis not associated with surgery. After a successful pilot study, the authors have recommended extending the indications of GES to include postsurgical gastroparesis. The authors are presently proposing GES be tested at the outset with temporarily placed electrodes. However, there seems to be good correlation of outcomes between temporary and permanent GES. As long as the stomach remains responsive to electrical stimulation, it only makes sense to implant permanent electrodes at the time of definitive surgery, leaving them subcutaneously accessible for later use, thus circumventing a second major surgery in an already debilitated individual. Successfully restoring gastric motility, albeit artificially, soon after esophagogastrectomy, can only jumpstart the process of nutritional repair and recovery.

Sadly, more than 50% of patients with esophageal cancer already have metastatic disease and are debilitated by poor nutrition at presentation. Nevertheless, esophagogastrectomy remains the standard of care for patients who have clinically resectable disease. In this complex setting, preserving and repairing nutrition remains a focus of attention before, during, and after surgery. The overall scenario may become more complicated by the use of multimodal induction therapy (ie, chemotherapy and radiotherapy) for this patient group followed by esophagogastrectomy and perhaps follow-up adjuvant therapy. In practical terms, more aggressive treatment translates into even more pressing problems of maintaining and improving nutrition during convalescence after esophagogastrectomy. The use of GES has the potential of removing the troubles caused by an atonic gastric remnant in these complex patients.

	References

Top References

 

1. McCallum RW, Chen JD, Lin Z, et al. Gastric pacing improves emptying and symptoms in patients with gastroparesis Gastroenterology 1998;114:456-461.[Medline]
2. Abell TL, Van Cutsem E, Abrahamsson H, et al. Gastric electrical stimulation in intractable symptomatic gastroparesis Digestion 2002;66:204-221.[Medline]
3. Salameh JR, Aru G, Bolton W, Abell T. Electrostimulation for intractable delayed emptying of intrathoracic stomach after esophagectomy Ann Thorac Surg 2008;85:1417-1420.[Abstract/Free Full Text]

This Article 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): Joseph Rubin Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Rubin, J. Search for Related Content PubMed PubMed Citation Articles by Rubin, J. Related Collections Esophagus - other Related Article