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LAPAROSCOPIC PLACEMENT OF GASTRIC STIMULATOR OF PATIENTS WITH POSTURAL ORTHOSTATIC TACHYCARDIA SYNDROME AND GASTROPARESIS: WHERE SHOULD THE LEADS GO?
Sullivan A. Ayuso
*, H. Mason Hedberg
Surgery, NorthShore University HealthSystem, Evanston, IL
Background: Patients with postural orthostatic tachycardia syndrome (POTS) manifest a variety of gastrointestinal symptoms, and 20% have gastroparesis. Gastric stimulation is a well-established treatment for diabetic gastroparesis, which is notably characterized by gastric denervation. While histologic comparisons to POTS are not available, it follows that delayed emptying in POTS (and perhaps other idiopathic gastroparesis) is not a process of denervation, but of dysfunction, and ideal lead placement may vary.
Methods: Retrospective chart review identified patients with POTS and gastroparesis from February 2023 to present. Basic demographic, procedural, and outcomes data were collected; standard statistics were used. Beginning in July 2024, leads were repositioned from the conventional greater curve placement to the lesser curve. The first two patients who received this lead placement were becoming malnourished due to intolerance of jejunal tube feeds, and were facing long-term parenteral nutrition. For these patients, conventional lead placement seemed unlikely to be of benefit. An in-depth informed consent process has been performed with each patient, and IRB approval for formal retrospective review is pending.
Results: A total of six patients met criteria for the study; 83.3% were female with mean age 25.8±8.2 years and mean body mass index 25.8±7.8 kg/m
2. The mean four-hour retention on GES was 25.9±12.3%. The chief complaint was nausea and vomiting for five of the six patients; the other presented with abdominal discomfort. The first patient was the only one with leads placed in the conventional location; there was no symptom improvement and the stimulator was explanted. The subsequent four patients had their leads placed along the lesser curvature, and for two of these patients a pyloroplasty was also performed. Each of these four patients reported significant symptomatic improvement. Of the three patients who were tube feed dependent prior to surgery, two no longer require tube feeds and the other is <1 month postop. There have been no explanations or complications from placement. The last patient included in this series has not had the stimulator implanted, but while undergoing neurological workup started wearing a transcutaneous median nerve stimulator that has dramatically improved nausea and vomiting. Mean follow-up time for these patients was 2.9±3.4 months.
Conclusions: In this small and short series of patients with gastroparesis and POTS, lead placement along the lesser curvature of the stomach has been able to avoid or reverse the need for parenteral and enteral nutrition in severely symptomatic patients. The relief gained by a similar patient by transcutaneous median nerve stimulation alone is fascinating, and may serve as a means to guide for ideal lead placement for those with idiopathic gastroparesis.
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