Gastric Electric Stimulation for Refractory Gastroparesis

Device migration/flipping most often occurs because the device is inadequately fixed to the underlying fascia, but occasionally it can occur from patients flipping the device around. Flipping can occur due to superficial pocket location within subcutaneous tissue, especially in obese patients. Migration/flipping can lead to prominence of the contour of the device and discomfort, ultimately requiring surgical correction.

Perforation and erosion of the leads. With time, leads can erode into the stomach, although this is rare. Usually erosion is associated with loss of device function. Endoscopy confirms this finding. In rare cases, infection can track proximally along the lead and present as a surgical site infection at the pulse generator. This complication often requires explantation of the neurostimulator leads and pulse generator.

Intestinal obstruction. Although rare, the intestines can get wrapped around the leads of the device, causing different degrees of obstruction (Figure 1). Positioning the device in the left upper quadrant minimizes the intraabdominal length of the leads and pulls them maximally out, coiling under the device (Figure 2). In cases where other locations are used either due to a hostile upper abdominal region (skin infection, presence of gastrostomy or other devices) or surgeon’s preference, the GES device can be implanted in the lower abdomen (Figure 3). In these circumstances, carefully draping the omentum over the bowels might help to prevent this complication. Tacking of the leads to the parietal peritoneum with sutures can also be preventative. In cases of obstruction requiring intervention by laparotomy or minimal access techniques (laparoscopy or robotic assisted surgery), all efforts are made to preserve the neurostimulator leads. In cases that require bowel resection, lead contamination is a serious concern, but lead explantation is not mandatory. Close postoperative monitoring for the development of lead infection is required.

Hematoma and seroma. Postoperative hematomas can occur from inadequate hemostasis, and seromas can occur in the stimulator pocket. Small hematomas may be observed if not complicated (Figure 4). In cases of large hematomas with skin compromise or dehiscence, prompt washout and drainage is required. In ideal cases, the device can be preserved. Relocation to another site might be required if skin necrosis develops. The possibility of device contamination also must be considered; after resolution of wound issues, implantation of a new device may be tried. Seromas at the generator pocket site are a frequent occurrence but are often benign, self-limiting, and generally resolve over 4 to 6 weeks.

Incisional hernia. Hernias can develop after any abdominal surgery and are not unique to GES implantation. Use of minimally invasive technique for the GES implantation minimizes this complication.