Amar Al-Juburi

Temporary gastric electrical stimulation with orally or PEG-placed electrodes in patients with drug refractory gastroparesis

BACKGROUND Gastric electrical stimulation (GES) has been shown to be efficacious for drug refractory gastroparesis, but GES requires surgery. Placement of temporary GES electrodes endoscopically (ENDOstim) or via a PEG (PEGstim) is feasible, thereby allowing rapid assessment and comparison of temporary use (TEMP) with permanent (PERM) implantation. METHODS Twenty consecutive patients with gastroparesis had TEMP electrodes placed (6 ENDOstim, 14 PEGstim). TEMP alone and TEMP vs. PERM placement of GES devices in 13 of 20 patients were compared via the following: average vomiting frequency score (VFS), total symptom score, days to symptom improvement, electrode impedance, and gastric emptying test. RESULTS For patients receiving TEMP, GES demonstrated a rapid, significant, and sustained improvement in VFS, results similar to those for PERM. CONCLUSIONS Both ENDO and PEG placement of GES electrodes are safe and effective in patients with gastroparesis, with outcomes that correspond to those achieved with permanent GES implantation.

Gastric Electrical Stimulation Is Safe and Effective: A Long-Term Study in Patients with Drug-Refractory Gastroparesis in Three Regional Centers

Background: Drug-refractory gastroparesis has previously been without acceptable alternative therapies. Although gastric electrical stimulation has been used for over a decade, no long-term multicenter data exist. Methods: We studied 214 consecutive drug-refractory patients with the symptoms of gastroparesis (146 idiopathic, 45 diabetic, 23 after surgery) who consented to participate in a variety of clinical research and clinical protocols at three centers from January 1992 through January 2005, resulting in 156 patients implanted with a gastric electrical stimulation device and the other 58 patients serving as controls. The patients were stratified into three groups: (1) consented but never permanently implanted; (2) implanted with permanent device, and (3) consented while awaiting a permanent device. The patients were followed over time for gastrointestinal symptoms, solid gastric emptying, health-related quality of life, survival, device retention, and complications. Demographics, descriptive statistics, and t tests were used for comparison between baseline and latest follow-up. Results: At latest follow-up, median 4 years for 5,568 patient months, most patients implanted (135 of 156) were alive with intact devices, significantly reduced gastrointestinal symptoms, and improved health-related quality of life, with evidence of improved gastric emptying, and 90% of the patients had a response in at least 1 of 3 main symptoms. Most patients explanted, usually for pocket infections, were later reimplanted successfully. There were no deaths directly related to the device. Conclusion: Based on this sample of patients, implanted with gastric electrical stimulation devices at three centers and followed for up toward a decade, gastric electrical stimulation for drug-refractory gastroparesis is both safe and effective.

Pilot study on gastric electrical stimulation on surgery-associated gastroparesis: Long-term outcome

Objectives: Patients with postgastric surgery gastroparesis are often unresponsive to conventional medical therapy. Gastric electrical stimulation (GES) with the use of high-frequency and low-energy neural stimulation is an approved technique for patients with idiopathic and diabetic gastroparesis. Methods: We hypothesized that GES would improve symptoms, health resource utilization, and gastric emptying in six patients with postsurgical gastroparesis from a variety of surgical procedures. Patients were evaluated by means of the following criteria: symptoms, health-related quality of life, and gastric emptying tests at baseline over time. Results: All patients noted improvements after device implantation for up to 46 months: the frequency score for weekly vomiting went from a baseline of 3.2 down to 0.4 immediately after treatment before settling at 1.4 by the long-term follow up. Total gastrointestinal symptom score went from 36.5 at baseline down to 12.3 before settling at 20.5 at long-term follow up. Improvements were also seen in health-related quality of life and solid and liquid gastric emptying. Conclusions: We conclude that GES is associated with clinical improvements in this group of patients with either postsurgical or surgery-associated gastroparesis. This pilot study with long-term outcomes offers evidence for a new therapy for otherwise refractory patients with gastroparesis associated with previous surgery.

CASE REPORT: Heterozygosity for Factor V Leiden and G20210A Prothrombin Genotypes in a Patient with Mesenteric Vein Thrombosis

Mesenteric vein thrombosis (MVT), an uncommon cause of ischemia or infarction of the small intestine, was first reported by Elliot (1) in the 19th century and recognized in 1935 as a distinct clinical entity by Warren and Eberhard (2). Acquired factors known to contribute to MVT include malignancy, immobilization, trauma, oral contraceptive use, and elevated levels of cardiolipin antibodies. MVT with no apparent underlying condition has been referred to as primary or idiopathic MVT and in earlier literature accounted for 25–55% of cases (3, 4). In recent years, hereditary risk factors have been increasingly implicated as a cause of MVT, especially with the discovery of two prothrombotic states: factor V Leiden mutation and the prothrombin G20210A genetic variation. The factor V Leiden mutation results in resistance to activated protein C, a natural anticoagulant (5). The prothrombin G20210A mutation is associated with elevated levels of functionally normal prothrombin and in heterozygous individuals is linked to a threefold increased risk of venous thrombosis (6). In this report, we describe a patient with MVT and factor V Leiden mutation plus G20210A prothrombin gene variation. Moreover, genetic analysis of the other family members revealed multiple hereditary defects that represent risk factors for thrombotic events. CASE REPORT

Efficacy of Gastric Electrical Stimulation for Gastroparesis: US/European Comparison

Background Gastric electrical stimulation (GES) is used in both the US and Europe, but little research has investigated the demographics of gastroparesis patients receiving GES by geographic location. Methods We compared data from 380 patients, 296 female and 84 males, mean age 42 years, 246 idiopathic (ID), 107 diabetic (DM), and 27 post-surgical (PS). The statistical significance was calculated by Chi-square test and a P-value obtained for ID, DM, and PS. The statistical significance was calculated by Fischer exact test and a P-value obtained comparing male vs. female. Results European centers had 61 GES patients compared to 319 from the US. In Europe, 100% of patients had gastric emptying test (GET) values available; in the US, it was 75% of patients. European centers had more DM patients (59%) than the US (22%), and a smaller proportion of ID patients (25%) than the US (72%). There was a statistical difference between the causes of gastroparesis in the patients receiving GES (P-value < 0.00001). There was also significant difference in the gender of the patients receiving GES, with a greater proportion of women in the US (P value = 0.0023). Conclusions Comparing GES in US vs. Europe demonstrated significant differences in gastroparesis demographics and percentage of patients with GET data. After analyzing the previously discussed results and reviewing recent updates in evidence-based medicine guidelines, the discrepancy and variance in patient populations in the US and Europe emphasizes the need for a database that allows better analysis and treatment of gastroparesis patients worldwide including stimulation therapies.

S1904 The Addition of Cracker Swallow to Standard Liquid Swallow for Determining Gastroesophageal Reflux Disease Severity in Ineffective Motility Disorder

patients registered in the PARSI database* were assessed for presence of abdominal pain. All these patients have detailed symptom recording as well as undergoing upper GI endoscopy. Endoscopic and clinical features of patients with epigastric pain were compared with those not complaining of this symptom. Results: A total of 1,124 patients (mean age 39.3 years, 56.1% female) were included. Of these 750 (66.7%) complained of epigastric pain, 52.4% of whom experienced it almost daily. Epigastric pain was the dominant symptom in 235 (40.4%) out of 581 participants whose dominant symptom was recorded. Frequency of epigastric pain was higher among women (71.8% vs. 60.2%, p-value<0.001). Furthermore, participants presenting with epigastric pain were significantly younger (37.6±14.2 vs. 42.7±15.3, p<0.001). Erosive reflux disease (ERD) was present in 656 (58.4%) and patients with epigastric pain had significantly lower prevalence of ERD than those without (55.1% vs. 65%, p=0.002). Interestingly, patients with epigastric pain were more likely to have normal stomach on endoscopy (46.6% vs. 36.7%, p=0.002). Finding a normal duodenum was equally likely between the two groups (75.8% vs. 71.8%p=0.162). Conclusion: Epigastric pain in patients with gastro-esophageal reflux disease is not associated with other upper GI pathologies. Instead it seems to be a symptom of GERD itself. Therefore, according to our data, we suggest patients with epigastric pain as their dominant complaint to be assessed for GERD even in the absence of prominent heartburn and acid regurgitation. *NasseriMoghaddam S, Razjouyan H, Alimohamadi SM, et al. Prospective Acid Reflux Study of Iran (PARSI): methodology and study design. BMC Gastroenterol 2007; 20:7:42.

S1928 Detection of Gastroesophageal Reflux Disease with Impedance pH in Preoperative Lung Transplant Patients

Introduction: An empiric trial of acid suppression with a proton pump inhibitor (PPI) is widely used as a diagnostic test for gastroesophageal reflux disease (GERD). However, the report about diagnostic value of a short trial with standard dose PPI is rare. The aim of this study was to determine the onset of symptom relief with standard or double dose of lansoprazole in Korean patients with erosive esophagitis or nonerosive reflux disease (NERD). Methods: This multi-center randomized study enrolled 93 patients with erosive esophagitis (n=30) or NERD (n=63) to receive lansoprazole treatment using 30 mg or 60 mg once daily for 14 days. Between two clinical visits (at enrolment and 14 days), patients were asked to keep a diary in which they recorded severity of GERD symptoms daily. Substantial symptom relief was defined as a more than 50% reduction in total symptom score. Results: In total patients, substantial symptom relief was achieved by the end of the first week (day 6). There were no significant differences of total symptom score reductions between standard and double dose groups of patients with erosive esophagitis. But onset of substantial symptom relief was faster in the double dose group (day 2) than the standard dose group (day 6). In patients with NERD, there were no significant differences of total symptom score reductions between standard and double dose group. Onset of substantial symptom relief was same in the standard and double dose groups of patients with NERD (day 8). Conclusions: In this multi-center, randomized study of Korean patients, standard-dose lansoprazole was as effective as double-dose lansoprazole in relieving symptoms by day 14 of treatment. Onset of substantial symptom relief was slower in the patients with non-erosive reflux disease than those with erosive esophagitis.