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Background: Gastric electric stimulation (GES) is used for refractory symptoms of gastroparesis. Although improvement in symptoms has been reported with GES, few studies have described the need for additional surgery after placement of gastric stimulators. The aim of this study was to evaluate the surgical outcomes of a large series of GES at a single institution. Secondary goals were to determine the need for additional surgery after insertion of GES.
Methods: A retrospective review of a prospective database was performed for patients undergoing GES placement for refractory gastroparesis at our single institution from 10/2000 to 10/2011. Demographic and clinical information was gathered from medical records.
Results: 266 patients had a GES implanted at our institution over the 11-year period. Medical records were available for 233 patients, with long-term outcome data for 74. All had delayed gastric emptying and refractory symptoms despite aggressive medical therapy. The mean age was 38 years (range 18-67), and 80% were female. The mean BMI was 24.8±6.7(SD), and pre-operative albumin level was 4.1±0.7(SD). The most frequent etiologies for gastroparesis were idiopathic (51.1%) and diabetic (42.9%). Common co-morbidities included depression/ anxiety (14.9%), chronic renal insufficiency (8.1%), and treated hypothyroidism (6.8%). GES were placed by 1 of 2 surgeons using a standardized surgical procedure and post-operative protocol. Mortality during the follow-up period was 2.1%, all unrelated to the procedure. The overall clinical outcomes for GES were favorable, with 70% of patients reporting improved symptoms. However, in a subset of patients, readmissions were common, with 90/233 patients re-presenting mainly for gastroparetic symptoms. The mean number of re-admissions for these 90 patients was 4.4 (range, 1-41). Additional surgery for nutrition was common- 45/233 patients required at least 1 procedure for nutritional access post-GES insertion. Reoperations were performed for device issues and surgical complications, including revision of GES stimulator in subcutaneous pocket (21), incisional hernia (4), battery failure (3), lead erosion (2), and small bowel obstruction (2). 12% of patients (29/233) had the GES explanted, mainly for continued gastroparetic symptoms(11), mechanical issues (9), and infection (4).
Conclusions: Although there is symptomatic improvement in most patients undergoing GES for refractory gastroparesis, a significant number of patients (34%) required additional surgery after GES placement. This need for additional surgery was most frequently for surgical nutrition (53%) for ongoing gastroparesis symptoms. Removal was performed in 12% of patients and revision of the GES pocket in 9% of patients. Despite these additional surgeries, the majority of patients report good overall outcomes for GES.

Table 1 Subsequent Surgical Procedures and Complications After GES Insertion

Nutrition
Central Access for TPN	21
PEG/ Gastrostomy Tube	19
Jejunostomy Tube	33
G-J Tube	4
SUBTOTAL	72
GES Explanted
No Relief of Symptoms	11
Mechanical Device Issues	9
Persistent Infection	4
Stimulator eroded through skin	3
Symptoms improved	2
SUBTOTAL	29
Revisions/ Surgical Complications
Revision of stimulator in subcutaneous pocket	21
Incisional hernia repair	4
Battery failure	3
Laparotomy for Small Bowel Obstruction	2
Lead erosion	2
Colectomy for Colitis	1
Takedown enterocutaneous fistula	1
SUBTOTAL	34
Non-Operative Surgical Complications
Wound Infection	5
Small Bowel Obstruction	4
Hematoma	2
Bleeding from Gastrostomy tube site	1
Suture Granuloma	1
Enterocutaneous Fistula	1
SUBTOTAL	14