Clinical Review

Gastric Electric Stimulation for Refractory Gastroparesis

Journal of Clinical Outcomes Management. 2019 January;26(1):27-38

Author(s):

Bryan Zoll

Asad Jehangir, MD

Zubair Malik, MD

Michael A. Edwards, MD

Roman V. Petrov, MD

Henry P. Parkman, MD

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References

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From Temple University School of Medicine, Philadelphia, PA.

Abstract

Objective: To outline the use and utility of gastric electric stimulation (GES) as a therapeutic intervention for gastroparesis.
Methods: Review of the literature.
Results: Gastroparesis is characterized by delayed gastric emptying, with symptoms of nausea, vomiting, early satiety, postprandial fullness, and abdominal pain. Some patients with gastroparesis do not respond to medical intervention, and for these patients surgical intervention may be warranted. GES utilizes high-frequency gastric neurostimulation to facilitate gastric emptying and reduce symptoms of gastroparesis. It is indicated for patients with idiopathic and diabetic gastroparesis who have nausea and vomiting as their primary symptoms and who have not responded to medical therapy. GES has also been used in postsurgical and pediatric gastroparesis patients. Optimizing the outcome of this surgical treatment through proper patient selection and meticulous surgical technique is essential as there are inherent risks to the procedure. Nonblinded studies of GES for medically refractory gastroparesis have demonstrated therapeutic symptomatic benefit, whereas randomized controlled trials have not. New interventions such as pyloromyotomy and pyloroplasty are reasonable alternatives or addendums to GES.
Conclusion: GES may be considered among the therapies available for treating patients with refractory symptoms of gastroparesis. More studies, specifically those comparing GES, pyloromyotomy, GES combined with pyloromyotomy, and placebo, are needed to help guide therapy selection for refractory gastroparesis.

Keywords: diabetes; gastroparesis; dysmotility; gastric emptying; electric stimulation.

Gastroparesis is a chronic dysmotility disorder characterized by delayed gastric emptying with associated symptoms of nausea, vomiting, early satiety, postprandial fullness, and abdominal pain. Medical treatments for gastroparesis include dietary modifications, glucose control in those with diabetes, prokinetic medications, antiemetic medications, and symptom modulators, but unfortunately patients frequently do not respond to these treatments. In patients refractory to medical therapy, surgical treatments can be considered.

Gastric electric stimulation (GES; Enterra [Medtronic, Minneapolis, MN]) was approved via a Food and Drug Administration (FDA) Humanitarian Use Device (HUD) exemption for the treatment of medically refractory gastroparesis in 2000. Understanding the indications, risks, outcomes, and alternatives to GES is essential to providing appropriate care for patients with medically refractory gastroparesis. This article outlines the use and utility of GES as a therapeutic intervention for gastroparesis.

Types of Gastroparesis

Gastroparesis is a chronic symptomatic disorder of the stomach manifested by delayed gastric emptying without evidence of gastric outlet obstruction or ulceration.¹ The pathophysiology of gastroparesis appears to involve abnormalities in functioning of several elements including the autonomic nervous system, especially the vagus nerve, smooth muscle cells, enteric neurons, and interstitial cells of Cajal.

Idiopathic gastroparesis and diabetic gastroparesis are the 2 most common types of gastroparesis.² Symptomatic delayed gastric emptying with no primary underlying abnormality predisposing to gastroparesis is categorized as idiopathic gastroparesis.³ A small subset of patients with idiopathic gastroparesis report an initial infectious prodrome such as gastroenteritis or respiratory infection. It has been suggested that this postinfectious gastroparesis results from viral injury to the neural innervation of the stomach or the interstitial cells of Cajal in the stomach.⁴ Viruses that have been implicated in the development of gastroparesis include cytomegalovirus, Epstein-Barr virus, Norwalk virus, rotavirus, herpes zoster, and varicella zoster.^5-9