A 48-year-old Caucasian male with a history of hypertension and poorly controlled type II diabetes mellitus presented with 4 months of early satiety, epigastric pain, heartburn, nausea, and daily emesis. An upper gastrointestinal endoscopy did not reveal any anatomic abnormalities. Scintigraphy demonstrated greater than 50% gastric content retention after 2 hours (Figure 1). Neither dietary changes nor Metoclopromide administration provided symptomatic relief. A diagnosis of drug-refractory diabetic gastroparesis was made and a laparoscopic gastric electrical stimulator implantation was planned.
The procedure requires 4 ports (Figure 2). Ten-mm ports are placed in the left upper quadrant (lateral gastric retraction) and umbilicus (camera) and 5-mm ports (working ports) are placed in the left lower and right upper quadrants. The surgeon stands on the patient's right side. The pylorus is identified, and a ruler is used to identify a point 10 cm proximal to it along the greater curvature, which is in the region of the pacemaker area. Marks are made with electrocautery 1 cm apart on the gastric serosa.
The lead is prepared by tying 2 silk sutures to its anchor. After the lead is inserted through the left upper quadrant port, the Prolene suture, which comes attached to the electrode, is placed through the seromuscular layers of the stomach. An upper gastrointestinal endoscopy assures that the gastric mucosa has not been violated. The Prolene suture is used to pull the electrode into the gastric muscularis propria. The electrode is secured to the gastric wall by using the silk suture, which had been previously tied to the anchor with the intracorporeal knot tying technique. The above procedure is repeated for a second lead with its electrode placed 1cm from the first.
The leads are brought out through the left upper quadrant port. An external programming device is used to confirm that the impedance between the 2 electrodes is between 200 and 800 Ohms. The electrodes are then further secured by placing a disc and 2 clips on the Prolene suture adjacent to the electrode (Figure 3).
An abdominal wall subcutaneous pocket is made for the stimulator 4 fingerbreadths below the left inferior costal margin. The leads are tunneled from the left upper quadrant port site to the subcutaneous pocket, where they are connected to the stimulator. Two sutures are used to secure the stimulator to the abdominal wall fascia. The pocket is closed in layers, and the stimulator parameters are set by using the external programming device. The voltage is calculated by multiplying the measured impedance by a current of 5 mA. The other parameters include a frequency of 14 Hz, a pulse width of 330 micros and a cycling time of 0.1 seconds on and 5 seconds off.
One month following surgery, the patient no longer required Metoclopramide. Two months later, he was symptom free, on an unrestricted diet with significantly improved glycemic control, and hemoglobin A1C within the normal range. At 6 months following surgery, a gastric scintigraphy demonstrated a normal pattern of gastric emptying with 22% gastric content retention at 2 hours (Figure 4).