Gastric electrical stimulation, pyloroplasty, gastrectomy, and acustimulation for the treatment of nausea and vomiting in the setting of gastroparesis

Abstract

Patients with severe symptoms of gastroparesis unresponsive to medical management may need treatment that is beyond the conventional methods available for the internist or a general gastroenterologist. Those drug refractory cases should be referred to a specialized motility center seeking the opinion of doctors whose clinical expertise reaches beyond the limited pharmacological interventions. Gastric electrical stimulation was originally developed for strengthening and regulating gastric slow waves and overcoming dysrhythmias. One method of stimulation is termed gastric pacing, by utilizing physiologic frequency and high energy to entrain gastric slow waves and reverse dysrhythmias, leading to improvement of gastric emptying. This has not been commercialized as yet. Another method is called neurostimulation, where a frequency of 12 cycles per minute is used to alleviate the symptoms but it does not alter the gastric slow waves, dysrhythmias, or gastric emptying. It is available as the Enterra therapy with FDA approval and this device is implanted either laparoscopically or by open laparotomy. To overcome the suboptimal symptom improvement provided by this device, a pyloroplasty is simultaneously performed to normalize the gastric emptying and hence maximize symptom improvement. A total gastrectomy is infrequently needed but is indicated when nausea and vomiting continues in the setting of a prior Billroth I or II gastric resection or where electrical stimulation alone (Enterra therapy) has failed to control symptoms of nausea and vomiting. Acupuncture has been used for the treatment of gastrointestinal symptoms in Eastern countries using the Neiguan (PC6) and the Zusanli (ST36) acupoints. Acustimulation produces an electrical current through a needleless electroacupuncture. This has been shown to be as effective in treating nausea and vomiting in gastroparesis patients.