Temporary Gastric Stimulation in Patients With Gastroparesis Symptoms: Low-Resolution Mapping Multiple Versus Single Mucosal Lead Electrograms.

BACKGROUND: Cajal cells have a fundamental role in generating slow waves that regulate gastric motility. Gastric electrical stimulation (GES) is Food and Drug Administration (FDA)-approved for symptomatic treatment of drug refractory gastroparesis. We hypothesized that using two leads will vary from a single lead by providing greater insight of gastric electrical wave propagation, through differences in measured frequency, amplitude, and frequency over amplitude ratio. We also hypothesized that a significant reduction in symptomatic vomiting score is highly predictive in a single lead temporary gastric electrical stimulation. METHODS: A total of 111 patients with drug-refractory gastroparesis were enrolled. Forty-two patients had single lead, while 69 patients had two leads. All recordings measured mean frequency and amplitude in each lead. Patients documented symptoms using standardized symptom scores at baseline and day 5 post-procedure. RESULTS: Single lead patients with initial low mucosal frequency showed an increase from 3.10 to 4.93 (P = 0.0155), while the high frequency group decreased from 5.89 to 5.12 (P = 0.135). Vomiting score decreased significantly among both groups with GES (P = 0.0001). For two leads, the mucosal frequency decreased at the proximal electrode (P = 0.402), and increased at the distal electrode (P = 0.514), neither statistically significant (P = 0.143). Mucosal electrogram amplitude values changed for both proximal, mean decrease of 0.34 mV (P = 0.241), and distal, mean increase of 0.05 mV (P = 0.65) with a mean difference 0.34 mV (P = 0.238). However, mucosal electrogram frequency and amplitudes on day 5 were highly dependent on the baseline values (P < 0.001). CONCLUSIONS: Compared to the use of single point electrodes, the use of two low-resolution electrodes allows recording gastric electrical wave propagation with greater detail. Low resolution recording appears to be superior to single point recordings, while awaiting practical high-resolution recordings.

Detecting initial orthostatic hypotension: a novel approach.

Our purpose, by modification of standard bedside tilt-testing, was to search for lesser known but important initial orthostatic hypotension (IOH), occurring transiently within the first 30 seconds of standing, heretofore only detectable with sophisticated continuous photoplethysmographic monitoring systems, not readily available in most medical facilities. In screened outpatients over 60 years of age, supine blood pressure (BP) parameters were recorded. To achieve readiness for immediate BP after standing, the cuff was re-inflated prior to standing, rather than after. Immediate, 1-, and 3-minute standing BPs were recorded. One hundred fifteen patients were studied (mean age, 71.1 years; 50.5% male). Eighteen (15.6%) had OH, of whom 14 (12.1%) had classical OH, and four (3.5%) had IOH. Early standing BP detection time was 20.1 ± 5.3 seconds. Immediate transient physiologic systolic BP decline was detected in non-OH (-8.8 ± 9.9 mm Hg; P < .0001). In contrast to classical OH (with lesser but persistent orthostatic BP decrements), IOH patients had immediate mean orthostatic systolic/diastolic BP change of -32.8 (±13.8) mm Hg/-14.0 (±8.5) mm Hg (P < .02), with recovery back to baseline by 1 minute. Two of the four IOH patients had pre-syncopal symptoms. For the first time, using standard inflation-deflation BP equipment, immediate transient standing physiologic BP decrement and IOH were demonstrated. This preliminary study confirms proof of principle that manual BP cuff inflation prior to standing may be useful and practical in diagnosing IOH, and may stimulate direct comparative studies with continuous monitoring systems.

Novel application of GI electrical stimulation in Roux stasis syndrome (with video).

BACKGROUND: About one-third of patients undergoing a Roux-en-Y anastomosis develop Roux stasis syndrome, likely because of disordered electrical conduction. GI electrical stimulation has been previously used successfully in the management of postsurgical gastroparesis. OBJECTIVE: Endoscopic placement of temporary electrodes and GI electrical stimulation in the management of severe Roux stasis syndrome in a patient with esophagojejunostomy and to determine whether the patient would be a candidate for surgical permanent electrode placement. DESIGN: Case report. SETTING: Academic medical center. PATIENTS: This study involved a patient with Roux stasis syndrome. INTERVENTION: Upper endoscopy was performed, followed by endoscopic placement of two temporary electrodes, one each in the two jejunal limbs. Electrical stimulation was provided by an external stimulation device. The patient was re-evaluated 5 days later. MAIN OUTCOME MEASUREMENTS: Electrogastrogram (EGG) parameters including frequency, amplitude, and frequency-amplitude ratio and total symptom score and health-related quality of life score. RESULTS: There was a significant improvement in EGG parameters with electrical stimulation. Also, the patient had a marked improvement in total GI symptom score, from 11 to 4, with a dramatic improvement in the health-related quality of life score from -3 to +3. LIMITATIONS: Single case report. CONCLUSION: Endoscopic placement of temporary electrodes is feasible and safe. GI electrical stimulation of the jejunal limb is a potentially effective treatment for Roux stasis syndrome.