Background: Gastric electrical stimulation (GES) has become an alternative for patients with gastroparesis that do not respond to medical treatment. Traditionally the GES leads have been placed in the stomach and the neurostimulator placed in a subcutaneous pocket in the abdominal wall. Our experience shows reduced incidence of surgical revision if the neurostimulator is placed in a subpectoral pocket.Methods: Retrospective chart review from 2001-2007 of 64 patients that had GES placement, 25 patients in the abdominal wall, 38 subpectoral and one infraclavicular. Data collected included need for surgical revision. The implantation procedure was done by open and laparoscopic technique depending on patient and surgeon preference. In both cases the pylorus was identified and the leads were placed into the muscularis of the stomach at 9.5 and 10.5cm from the pylorus. An upper endoscopy was preformed to ensure that the leads did not transgress the mucosa. The leads were anchored into the stomach, then tunneled either to a pocket in the abdominal wall or subpectoral pocket previously created.Results: Fourteen surgical revisions of the gastric stimulator were performed in 11 patients ( eight abdominal and one infraclavicular): two due to lead fracture, eight due to abdominal pain, one due to migration of a lead into the stomach, one due to migration of the stimulator toward the J-tube, one patient that the GES pushed up against the rib cage causing pain and one placed subclavicular with pain at the site. No revisions were performed in the subpectoral group. The estimation of risk adjusted by sex, age and diabetes showed that abdominal pacer had a greater risk of revisions compared to subpectoral placement with hazard ratio of 7.1 CI 95%:0.86-59.5, p=0.06.Conclusions: This is the first report of placing the GES in the subpectoral position. We believe that 80% (12/14) of our revisions could likely have been prevented with subpectoral placement. Patients with abdominal placement of the device were more likely to have discomfort leading them to manipulate or attempt to shift the device resulting in lead failure and connection break. Abdominal placement was also found to have more pain at the site requiring device revision. Subpectoral placement in our experience may limit the amount of revisions and pain associated with the device. Longer term follow up is needed in this group of patients.