Find us on Google+ Gastroparesis

Saturday, August 26, 2017

Spreading Positivity in the GP Community: Healing the Rift

I have touched on this before but I thought it was worth repeating. There are a lot of diverse groups that make up the gastroparesis community on social media. There are so many different variety of groups, so that you can usually find a support group that works for you and your needs. This is a very positive thing because gastroparesis can be very isolating. There are times where I feel like I am on house arrest. For instance, it is really hard for me to go places and do things with my friends/family because I vomit so frequently. Some of my friends will start vomiting if they see me do it, so that does not really work out. There are SO many positives to gastroparesis groups:

1. People know where you are coming from
2. People believe you so you do not have to constantly defend yourself
3. You get the support you need from a group set going through the same things
4. You can ask and answer questions
5. You make new friends
6. You get involved with the gastroparesis community
7. You do not have to censor yourself, because there is no such thing as TMI (too much information) in a support group
8. You can join multiple groups (it is better to do this since groups have specialities or if you want different perspectives)
9. It is nice to connect with others, especially if you are alone
10. You have the ability to help the newly diagnosed and share your experiences with them

Those are the positives that I love seeing in groups. The gastroparesis groups can be welcoming and inviting but you might have to search around until you can find one that is the fit for you. Usually, people in groups are willing to give suggestions to direct you to other groups if you feel like the one you joined is not the fit for you.

I have a list of gastroparesis resources here: HERE.

Now, I want to address something else, the negative sides of gastroparesis groups and by extension, the community. There seems to be a huge rift in our gastroparesis community at the moment and it seems to focus on each of the gastroparesis groups doing their own things. It does NOT matter how the rift in the groups began, who is at fault, because ultimately, we are hurting our main goal - which is gastroparesis awareness, and most importantly, each other.

Our community needs to heal and come together to work together to try and fight doctors, nurses, and others who think that gastroparesis is NOT real, despite test results that tell the contrary. It is a waste of our energy to fight one another when we should all be working towards a common goal. Instead, we are shooting ourselves in the foot and before long, no one is going to take us seriously. With all of this squabbling and fighting amongst each other, we are losing sight of the real message: to spread awareness about our illness. It's not a competition and we do have a common goal.

Therefore, this needs to end.

We are better than this. We need to work on making sure people know what gastroparesis is, how it effects so many, their quality of life, and to fight for those who barely have the energy to fight for themselves. We also need to dispense with the blame game. This fracturing is devastating to our community. Furthermore, even people in other support groups, like the cancer and stroke groups, are inquiring as to what is going on with the gastroparesis community. This has gotten out of hand and needs to stop. We cannot take the community out of gastroparesis community.

You do not have to like someone, but you CAN respect them.

All of the cliques, the in fighting, back biting, passive aggression - ALL OF IT, in groups needs to end. That is NOT what support is. It is hurting our cause instead of helping it. All of us have worked hard to get the community where it is today. It's taken a lot of work from so many people, and it is a very thankless job which we do for free in our spare time. We all do it because we love this community but also because it is important for us to find better treatment plans, and hopefully, a cure. We have lost THIRTY-FOUR people in the past two to three months. Let that sink in for a minute. We should honor those fallen warriors by continuing to promote awareness for gastroparesis.

No awareness, no research, no cure.

This giant rift in the gastroparesis community needs to close. No one needs to take sides. Instead, take the side of gastroparesis, and fight with everything you have to spread awareness, spread joy to those who are feeling down, spread friendship to those with this illness who are isolated. There are so many positives we could be doing! The gastroparesis community needs to come together and help each other out.

I would be happy to promote other groups, pages, etc, just like I have always done. To me, getting the word out matters and politics does not. I just do not understand how this happened in our community. But, I do want to rescue it and work with others before we lose all credibility completely. Like I previously stated, we already have a hard enough time fighting doctors, hospitals, and everything else. We all should look out for one another. We are a strong community, but we need to heal and move forward.

Image taken from:

According to Senior Outlook (,

"Even good relationships can be damaged by an argument, jealousy, misunderstanding, insult, rumor, or buildup of small resentments.

Sometimes things blow over quickly, but other times the upset lasts for years or even indefinitely. As time passes, people may even forget why they originally became upset.

Meanwhile, discord eats away at the peace of mind of those involved, and that affects the body. Negative emotions can release adrenaline and cortisol, chemicals useful in short-term fight-or-flight responses but destructive to the immune system when circulated in the bloodstream for extended periods. Augustine of Hippo (St. Augustine, 354–430 A.D.) wrote, 'Resentment is like taking poison and hoping the other person dies.'

Further bodily damage can be wrought. Many believe the mind delivers to your body whatever you speak, think, or otherwise focus on. If true, what bodily symptoms might result from expressing such thoughts as 'He’s a real pain in the neck/butt,' 'She makes me sick,' or 'I’m so sick and tired of that guy?'

Friends surrounding this ailing relationship are affected, too. After a friendship breaks up, party hosts may rightly invite both feuding friends; but then they may be asked awkward questions regarding whether the other person plans to attend. If both individuals attend anyhow, they may avoid or confront one other, making others uncomfortable.

What about innocent bystanders within the family—parents, children, siblings, and grandparents? Some family members feel forced to choose sides if two of their children or siblings aren’t speaking to each other. And how do you manage family holidays together? A schism within the family destroys peace.

All these unpleasant side effects are ample incentive to try to mend the torn relationship and restore peace and harmony between the two of you and among those dear to you both.

Writing a reconciliation letter is a good first step. Deliver your truth with compassion. Start with a sincere compliment or other positive statements; then create an emotional connection by mentioning what you’ve always enjoyed about each other or what you once enjoyed doing together—times you both treasured.

Acknowledge that no two people ever perceive or recall a situation in exactly the same way. Truthfully but kindly describe the situation—as you recall it—that you believe has caused the current upset. Avoid starting sentences with 'You,' such as 'You said,' as these statements seem accusatory. Instead, describe your own feelings in response to circumstances at the heart of the upset, e.g., 'I was devastated when I heard that statement made in front of everyone at the party.'

Accept responsibility and apologize for any part you may have played in the upset. Then ask for and/or extend forgiveness—whatever is appropriate. End by expressing hope of reconciliation, or at least an agreement to 'live and let live,' for personal peace as well as harmony among affected family and friends.

To allow the other person a chance to offer a considered response, not an emotionally charged one, mail your letter. Don’t ask for signed proof of delivery; this could be interpreted as a pressure tactic or power play. Just write 'Personal & Confidential—Please Deliver Unopened' to the right of your return address to help ensure privacy.

If you receive no response within a month, send a brief note stating you hope the note finds him or her well, you care about your relationship, and you’re hoping to hear from him or her regarding the letter you sent on (date). Consider attaching a duplicate of the letter, just in case.

With that, you’ll know you’ve made your best peacemaking effort; accept the outcome. Forgive yourself, if you haven’t already, for anything you might have contributed to the upset, because this, too, is healing. Finally, should you find yourself face to face with the other person, behave as if the upset never happened in the first place. This makes it easy, if the other person so desires, to gracefully resume that good relationship, without embarrassment or any need to explain.

And if, in the future, any resentment toward the other person creeps back into your thoughts, immediately forgive him or her mentally, and then once again forgive yourself. Repeat as often as needed."

The community needs to band together once more and fight for one another, not fight each other.

Hirschsprung's Disease

One of my friends was recently diagnosed with this disease, and I have to admit that I had no clue about it. I knew about little to no colon motility, but I never knew that this had a name. There are lots of things that can slow the colon or stop it working completely, like scleroderma, Ehler Danlos Syndrome, and Gastroparesis. I wanted to do some research on Hirschsprung's Disease to see what information I could find to help others who may be suffering from the same thing.

According to the Atlas of Pathophysiology (,

"Hirschsprung's disease, also called congenital megacolon or congenital aganglionic megacolon, is a congenital disorder of the large intestine, characterized by absence or marked reduction of parasympathetic ganglion cells in the colorectal wall. Hirschsprung's disease appears to be a familial, congenital defect, occurring in 1 in 5,000 to 1 in 8,000 live births. It's up to 7 times more common in males than in females (although the aganglionic segment is usually shorter in males) and is most prevalent in whites. Total aganglionosis affects both sexes equally. Females with Hirschsprung's disease are at higher risk for having affected children. This disease usually coexists with other congenital anomalies, particularly trisomy 21 and anomalies of the urinary tract such as megaloureter."

Image taken from:

According to the Mayo Clinic ('s-disease/home/ovc-20214664), the symptoms of Hirschsprung's Disease are included but not limited to,

"Hirschsprung's (HIRSH-sproongz) disease is a condition that affects the large intestine (colon) and causes problems with passing stool. The condition is present at birth (congenital) as a result of missing nerve cells in the muscles of the baby's colon.

A newborn who has Hirschsprung's disease usually can't have a bowel movement in the days after birth. In mild cases, the condition might not be detected until later in childhood. Uncommonly, Hirschsprung's disease is first diagnosed in adults.

Surgery to bypass or remove the diseased part of the colon is the treatment."

Image taken from:

However, even though it is rare or uncommon, adults can very much get it as well.

The symptoms, according to Mayo ('s-disease/symptoms-causes/dxc-20214666), are,

"Signs and symptoms of Hirschsprung's disease vary with the severity of the condition. Usually signs and symptoms appear shortly after birth, but sometimes they're not apparent until later in life.

Typically, the most obvious sign is a newborn's failure to have a bowel movement within 48 hours after birth.

Other signs and symptoms in newborns may include:

Swollen belly

Vomiting, including vomiting a green or brown substance

Constipation or gas, which might make a newborn fussy


In older children/adults, signs and symptoms can include:

Swollen belly

Chronic constipation


Failure to thrive


It's not clear what causes Hirschsprung's disease. It sometimes occurs in families and might, in some cases, be associated with a genetic mutation.

Hirschsprung's disease occurs when nerve cells in the colon don't form completely. Nerves in the colon control the muscle contractions that move food through the bowels. Without the contractions, stool stays in the large intestine.

Factors that may increase the risk of Hirschsprung's disease include:

Having a sibling who has Hirschsprung's disease. Hirschsprung's disease can be inherited. If you have one child who has the condition, future biological children could be at risk.

Being male. Hirschsprung's disease is more common in males.

Having other inherited conditions. Hirschsprung's disease is associated with certain inherited conditions, such as Down syndrome and other abnormalities present at birth, such as congenital heart disease."

Image taken from:

According to MedicineNet (,

"The cause of Hirschsprung disease is due to nerve cells that are supposed to grow along the intestine and reach the anus, but do not because they stop growing too soon. Hirschsprung disease (HSCR) is a congenital (present at birth) disease of the large intestine or colon. It is one type of birth defect. People with the disease do not have the nerve cells in the intestine required to expel stools from the body normally.

Some people inherit the disease, and others have mutations in several genes. In about 50% of people with Hirschsprung disease, researchers and doctors do not know what genes cause it.

Your primary care doctor will refer you to a specialist in digestive disorders called a gastroenterologist, to diagnose the condition. Diagnosis for Hirschsprung’s is based on a physical exam, medical and family history, symptoms, and tests, for example, a digital exam.
Surgery is the treatment for this life-threatening disease (procedures include pull-through for infants and ostomy (An ostomy refers to the surgically created opening in the body for the discharge of body wastes) for toddles and older children).

After healing from surgery, your child's bowel movements may become normal. But surgery doesn't cure Hirschsprung disease. Some children/adults will have bowel problems – like constipation or fecal incontinence (“accidents”) – off and on throughout their lives.

Symptoms of Hirschsprung disease in toddlers and older children may include:

Not being able to pass stools without enemas or suppositories. An enema involves flushing liquid into the child’s anus using a special wash bottle. A suppository is a pill Placed into the child’s rectum.

Swelling of the abdomen.

Diarrhea, often with blood.

Slow growth.

Intellectual disability"

Image taken from:

According to Science Direct (,

"Some patients reach adulthood without a diagnosis for this disease. Typically, patients go to the doctor with a long-standing history of constipation requiring frequent laxative use.11 The current frequency of the disease in adults is unknown, especially since HD is an overlooked and misdiagnosed disease in this age group. ...the diagnosis of HD is supported by barium enema studies, anorectal manometry and rectal biopsy.

Imaging studies such as computed tomography (CT) and barium enemas are usually accepted for evaluation of chronic constipation, which is a common disorder in adults. Our patient underwent CT due to the unavailability of a barium enema study, but CT is a more expensive method.

The anorectal manometry, even though not contributing in the present case, is an ancillary test of the utmost importance, since the presence of the rectum-anal reflex in this exam usually rule out the diagnosis of HD.

Several procedures are used to manage this disease after childhood; currently the option of choice is the surgical procedure of Duhamel. Late diagnosis contributes to the need for surgery in more than one surgical time, with ileostomy or colostomy, since the healthy colon is more distended in adolescents and adults compared to neonates and children. Nevertheless, the literature considers as the procedure of choice the Duhamel technique in only one surgical time, which reduces the hospitalization time.

This surgery is considered curative. However, post-operative bowel functioning is not always satisfactory. Enterocolitis, constipation and fecal incontinence represent the main postoperative complications in children. To date, the progression for adolescent or adult patients is not fully clarified yet, due to the small number of reported cases."

Image taken from:

I really hope this will help educate you about Hirschsprung disease. I am still learning about it myself. The research I did says it is more likely to happen with children, but adults I know have it and were just officially diagnosed. After you have a rectal biopsy (because doctors do a biopsy to verify you do have HD), then they might do an anorectal manometry (which is where they stick a balloon up your rectum, kind of like the pelvic floor test). Once all of that has been confirmed, then they might start talking reconstructive pelvic surgery.

I would still advise you to be cautious, do your own research, talk to people who have had it done, and make an informed decision so you will know if this is right for you. Thank you very much to my friend who brought this illness to my attention, because I had no idea this was going on. My heart goes out to all of you who are fighting this on a daily basis.

Thursday, August 3, 2017

Cyber Bullying and the GP Community

There has been a lot of bullying going on within the gastroparesis community, a lot of which has been aimed at me. I keep getting harassed, had former friends harass me, my pages, and my blog. My blog has been the crux of this issue a few times. I want to say that my blog is not a scientific journal, so it is not peer reviewed. It's a blog. I've been told that twice by the same person. I have been published in two geological journals, but I do not think the lead count in soil would help any GPers I know.

GP isn't a social club. It's about working together to get the information out there and to help those who have GP. It is not about ganging up on people, controlling groups, pages, etc. It's about support, pure and simple. There are so many obstacles that we have to go through with gastroparesis, we shouldn't manufacture more, we should stand united. We need to educate those who may not know about gastroparesis and what that entails. It's August - GP Awareness Month. We should rally together to educate, not tear each other down. Divided we fall, united we conquer.

I want to talk about cyber bullying, since I'm experiencing it firsthand, and what it's doing to the gastroparesis community. I also want to help others who may be going through the same things. It's hard being bullied, especially if Facebook won't listen and you don't have any other recourse. I'll share some things I have learned and some tips from an anti-bullying site that I found. We should be building each other up and not tearing each other down. Having gastroparesis is hard enough, and we face enough adversity from doctors, nurses, ER staff, etc, we don't need it from each other.

So, here's what you can do to avoid cyber bullying.

1. Do not feed the troll. What I mean by that is, do not give the person fuel for their fire to keep attacking you. As hard as it is, stay silent. These people crave attention and will try to get it by any means necessary.

2. Block these people. They have no control over your life unless you let them. You are better off without these toxic people in your lives. You ARE important, and don't let these people have control over what you do.

3. Write yourself an email. Every time these people hurt you and you want to say something back, write yourself an email and send it to yourself to get your feelings out. That way, you don't bottle it up and you can get out what you want to say. You don't need to send it to anyone else, this is just for you.

4. Do not be scared. Don't be scared to login to Facebook or wherever these trolls might be lurking. That would be giving them power over you. Don't let them. You're better than that, and like it or not, these people are going to be everywhere so there is really not a way to avoid them.

5. Do not give in. These people want something from you, don't give it to them. Bullies usually won't stop until they can get what they want. I will give an example. This is a popular one - in movies and T.V. shows - bullies want lunch money. They will not stop punching you in the gut until they get it and run off. So, don't give the bullies your "lunch money."

6. Do not stop living your life. The thing with bullies is that they will try to interrupt as much of your life as possible. Do not let them. The world spins on. You should keep living your life and do not let them make you deviate from it, because that is their goal.

I would also check with your state and see what laws they may have in place about cyber bullying.


According to,

"We get a lot of emails, phone calls, and comments on this blog from adults who are being bullied though technology. They stress to us that cyberbullying is not just an adolescent problem. Believe me, we know. We receive more inquiries from adults than teens. We know that cyberbullying negatively affects adults too. It’s just that we spend the majority of our efforts studying how this problem impacts school-aged youth due to their tenuous developmental stage. That said, I thought I would take some time here to give the adults who have been victimized out there some general advice.

First, it is important to keep all evidence of the bullying: messages, posts, comments, etc. If there are ways you can determine who exactly is making the comments, also document that. Second, contact the service or content provider through which the bullying is occurring. For example, if you are being cyberbullied on Facebook, contact them. If you are receiving hurtful or threatening cell phone messages, contact your cell phone company to obtain assistance. Along those same lines, familiarize yourself with the Terms of Use for the various sites you frequent, and the online accounts you sign up for. Many web sites expressly prohibit harassment and if you report it through their established mechanisms, the content and/or bully should be removed from the site in a timely manner. To be sure, some web site administrators are better and quicker at this than others.

Also, please be careful not to retaliate – or do anything that might be perceived by an outsider to have contributed to the problem. Do not respond to the cyberbully except to calmly tell them to stop. If they refuse, you may have to take additional actions. If you are ever afraid for your safety, you need to contact law enforcement to investigate. They can determine whether any threats made are credible. If they are, the police will formally look into it. The evidence that you have collected will help them to evaluate your situation.

You should also take the time to check your state laws. We have discussed some of these laws on this blog and have a summary of many applicable laws here. In Wisconsin, for example, it is a misdemeanor if someone uses computerized communication systems to “frighten, intimidate, threaten, abuse, or harass another person.” It is also against the law to “harass annoy, or offend another person.” See what the laws in your state are to determine if the police should get involved.

If the threats or comments are detrimental to your health, safety, or occupation, you might want to consult with an attorney who specializes in harassment, defamation of character, false light, intentional infliction of emotional distress, or similar types of civil action. A letter sent from an attorney (on law firm letterhead) to the bully may be all that is necessary to get the bullying to stop. The problem with this approach is that it can be costly. I have spoken to some victims who have consulted with attorneys who want a significant sum of money to get involved, even at a basic level. I can only imagine how frustrating this is after experiencing emotional and psychological suffering – and then realizing that you can’t afford to get legal help. Another problem associated with pursuing a bully through civil action is that, even if you are successful and a judge or jury rules in your favor, it can be difficult to determine an appropriate damage amount. I served as an expert witness in a cyberbullying case in the summer of 2008. In that case, the adult victims were being bullied in an AOL chat room. Everyone agreed that what the bully was doing was wrong, but to what were the victims entitled? They had some modest medical bills and could be reimbursed for costs associated with their AOL account – but these losses added up to less than $1,000. And while I don’t know the actual amount, I am sure their legal bills were in the tens of thousands of dollars. They ended up settling for a very small amount – just to make a statement to the bully. Most of us can’t afford to take those actions on principle alone.

In sum, it can be difficult to hold bullies accountable for their actions (for both adolescents and adults). In a country such as ours that values free speech so highly, many people genuinely believe they can say whatever they want, to whomever they want. We know that is not true, but it isn’t clear where exactly the line is. And just because we *can* say certain things, doesn’t mean we should. It’s no wonder that many teens are wrestling with this problem—they see the adults in their lives saying mean and nasty things to others on a regular basis. Do your part to model appropriate behavior and address any hurtful language when it comes up. The kids (and other adults) in your life will hopefully see it, remember it, and act in the right ways."

I know first hand what bullying feels like and it is not the most pleasant feeling. It is so hard to stay silent when people are attacking you left and right. The hardest thing you can do is to keep your peace and not feed into what they want, which is any kind of reaction out of you. Anything you say in your defense will just be used against you later in one form or another, and just give them more fuel for their fire. It is so hard to sit back and watch people defame you, your character, your family, your contributions to the community, or whatever they feel the need to target. It hurts. I know it hurts so much. I have cried over things that were said and done to me.

It hurts so much, and the worst feeling that you feel is powerless. But, you are NOT powerless. You have a lot more power than you know of. By not feeding into this hate, you are breaking the bullying cycle. Be sure to document EVERYTHING! You can keep a file with print outs of what has been said about you, if it was online. If it is through the phone company, save your voicemails. Gather all of the evidence that you can, while you can. You can look up cyber bullying or bullying laws in your state, it varies, but there are legal courses of action that one can take. I would also recommend talking to a therapist to get out all of your feelings regarding the way you are being treated. Your therapist might have some great ideas on how to deal with a bully as well. Just know that you are NOT alone! You do NOT have to go through this alone! You are special, here for a reason, and no one is worth it if all they do is tear you down. You are amazing and in case no one has told you this today, I believe in you.


I wanted to share my favorite poem because it has gotten me through some really rough times and it might help someone else. It comforts me when I'm at my lowest. I had to memorize it in middle school but I still love it to this day. If it will help or reach someone who is going through a tough time, then I'm glad. I recite it to myself when I feel defeated or upset. It's a really great poem.



If you can keep your head when all about you
Are losing theirs and blaming it on you,
If you can trust yourself when all men doubt you,
But make allowance for their doubting too;
If you can wait and not be tired by waiting,
Or being lied about, don’t deal in lies,
Or being hated, don’t give way to hating,
And yet don’t look too good, nor talk too wise:

If you can dream—and not make dreams your master;
If you can think—and not make thoughts your aim;
If you can meet with Triumph and Disaster
And treat those two impostors just the same;
If you can bear to hear the truth you’ve spoken
Twisted by knaves to make a trap for fools,
Or watch the things you gave your life to, broken,
And stoop and build ’em up with worn-out tools:

If you can make one heap of all your winnings
And risk it on one turn of pitch-and-toss,
And lose, and start again at your beginnings
And never breathe a word about your loss;
If you can force your heart and nerve and sinew
To serve your turn long after they are gone,
And so hold on when there is nothing in you
Except the Will which says to them: ‘Hold on!’

If you can talk with crowds and keep your virtue,
Or walk with Kings—nor lose the common touch,
If neither foes nor loving friends can hurt you,
If all men count with you, but none too much;
If you can fill the unforgiving minute
With sixty seconds’ worth of distance run,
Yours is the Earth and everything that’s in it,
And—which is more—you’ll be a Man, my son!"


Saturday, June 10, 2017

The Vagus Nerve Stimulator

The Vagus Nerve Stimulator (VNS) is a medical treatment that involves delivering electrical impulses to the vagus nerve. The Vagus Nerve Stimulator, which is new to me so I wanted to do research on it, definitely would help a variety of conditions like epilepsy, depression, multiple sclerosis, headache, pain and Alzheimer's disease. It would probably even help with gastroparesis as well, though I'd check with your doctor first to be one hundred percent sure. Gastroparesis and DTP are caused by vagus nerve damage. If it sends electric impulses down your vagus nerve, it might help your stomach muscles contract and help with gastric emptying. There isn't enough research about Gastroparesis and the VNS so I cannot give you a definitive answer on whether it would help with Gastroparesis or not. However, I did research on the VNS itself, below, because I am not really familiar with it yet. I hope the research helps and I am going to mention this procedure to my GI to see if he would recommend it or if it can be used for Gastroparesis. It has been approved by the FDA for cluster headaches, which I found interesting reading the articles below.

If you are not familiar with the vagus nerve and how much it controls, please read my other article. The link is below:


The Mayo Clinic describes the Vagus Nerve Stimulator (VNS) as:

"Vagus nerve stimulation is a procedure that involves implantation of a device that stimulates the vagus nerve with electrical impulses.

There's one vagus nerve on each side of your body, running from your brainstem through your neck to your chest and abdomen.

Vagus nerve stimulation is most often used to treat epilepsy when other treatments haven't worked. Vagus nerve stimulation is also a treatment for hard-to-treat depression that hasn't responded to typical therapies.

Researchers are currently studying vagus nerve stimulation as a potential treatment for a variety of conditions, including multiple sclerosis, headache, pain and Alzheimer's disease.

In conventional vagus nerve stimulation, a device is surgically implanted under the skin on your chest, and a wire is threaded under your skin connecting the device to the left vagus nerve. The right vagus nerve is not used because it carries fibers that supply nerves to the heart.

When activated, the device sends electrical signals along the vagus nerve to your brainstem, which then sends signals to certain areas in your brain.

New, noninvasive vagus nerve stimulation devices, which do not require surgical implantation, have been approved for use in Europe to treat epilepsy, depression and pain but have not yet been approved for use in the U.S. An implantable device that stimulates the right vagus nerve is also under study for the treatment of heart failure.

Before the procedure

Before surgery, your doctor will do a physical examination. You may need blood tests or other tests to make sure you don't have any health concerns that might be a problem.

Your doctor will have you start taking antibiotics before surgery to prevent infection.

During the procedure

Surgery to implant the vagus nerve stimulation device is done either on an outpatient basis, allowing you to go home that same day, or on an inpatient basis, requiring an overnight stay in the hospital.

The surgery usually takes one to two hours. You may remain awake but have medication to numb the surgery area (local anesthesia) or you may be unconscious during the surgery (general anesthesia).

The surgery itself doesn't involve your brain. Two small incisions are made, one on your chest and the other on the left side of the neck.

The pulse generator is implanted in the upper left side of your chest. The device is meant to be a permanent implant, but it can be removed if necessary.

The pulse generator is about the size of a stopwatch and runs on battery power. A lead wire is connected to the pulse generator. The lead wire is guided under your skin from your chest up to your neck, where it's attached to the left vagus nerve through the second incision.

After the procedure

The pulse generator is turned on during a visit to your doctor's office a few weeks after surgery. Then it can be programmed to deliver electrical impulses to the vagus nerve at various durations, frequencies and currents.

Vagus nerve stimulation usually starts at a low level and is gradually increased, depending on your symptoms and side effects.

Stimulation is programmed to turn on and off in specific cycles. You may have some tingling sensations or slight pain in your neck when the nerve stimulation is on.

Usually, the stimulations are set to occur every one to three minutes. Programming is performed at the physician's office using a hand-held programming device.

The stimulator doesn't detect seizure activity or depression symptoms. When it's turned on, the stimulator turns on and off at the intervals selected by your doctor.

You'll be given a hand-held magnet so that you can initiate a stimulation yourself if you or others sense the beginning of a seizure.

The magnet can also be used to temporarily turn off the vagus nerve stimulation, which may be necessary when you do certain activities such as public speaking, singing or exercising, or when you're eating if you have swallowing problems.

You must visit your doctor periodically to make sure that the pulse generator is working correctly and that it hasn't shifted out of position. Most people see their doctor once or twice a year for this purpose.

You should also contact your doctor before you have any medical tests, such as magnetic resonance imaging (MRI), which might interfere with your device, or have another medical device implanted.


Vagus nerve stimulation isn't a cure for epilepsy. Most people with epilepsy won't stop having seizures or taking epilepsy medication altogether after the procedure.

But many will have fewer seizures, up to 20 to 50 percent fewer. Seizure intensity may lessen as well.

It can take as long as 18 months of vagus nerve stimulation before you notice any significant reduction in seizures. Vagus nerve stimulation may also shorten the recovery time after a seizure.

People who've had vagus nerve stimulation to treat epilepsy may also experience improvements in mood and quality of life.

Research is still mixed on the benefits of vagus nerve stimulation for the treatment of depression.

Some studies suggest the benefits of vagus nerve stimulation for depression accrue over time, and it may take several months of treatment before you notice any improvements in your depression symptoms.

In addition, vagus nerve stimulation doesn't work for everybody, and it generally isn't meant to replace traditional treatments.

Additionally, some health insurance carriers may not pay for this procedure.

Studies of vagus nerve stimulation as a treatment for conditions, such as Alzheimer's disease, migraine and multiple sclerosis, have been too small to draw any definitive conclusions about how well it may work for those problems. More research is needed."

In vagus nerve stimulation, an implanted pulse generator and lead wire stimulate the vagus nerve, which leads to stabilization of abnormal electrical activity in the brain.

According to Wikipedia, it has a lot of different medical uses such as,

"Because the vagus nerve is associated with many different functions and brain regions, research is being done to determine its usefulness in treating other illnesses, including various anxiety disorders, Alzheimer's disease, migraines, fibromyalgia, obesity, and tinnitus.

Alcohol addiction
Atrial fibrillation
Bulimia nervosa
Burn-induced organ dysfunction
Chronic heart failure
Chronic intractable hiccups
Comorbid personality disorders
Coronary artery disease
Dravet syndrome
Heroin seeking behavior
Intestinal epithelial barrier breakdown
Lennox–Gastaut syndrome
Mood disorders in elderly population
Multiple sclerosis
Obsessive compulsive disorder
Peripheral arterial occlusion disease
Postoperative cognitive dysfunction in elderly patients
Rasmussen's encephalitis
Severe mental diseases
Spinal trigeminal neuronal
Transient focal cerebral ischemia
Trauma-hemorrhagic shock
Traumatic brain injury
Vaginal-cervical self-stimulation in women with complete spinal cord injury
Vegetative states after traumatic brain injury
Visceral pain-related affective memory
Other brain stimulation techniques used to treat depression include electroconvulsive therapy (ECT) and cranial electrotherapy stimulation (CES). Deep brain stimulation is currently under study as a treatment for depression. Transcranial magnetic stimulation (TMS) is under study as a therapy for both depression and epilepsy. Trigeminal Nerve Stimulation (TNS) is being researched at UCLA as a treatment for epilepsy."

Unless you have a surgically implanted device you actually cannot directly stimulate your vagus nerve; however, you can indirectly stimulate your vagus nerve to relieve keyed up or shut down nervous system states. Remember, your vagus nerve passes through your belly, diaphragm, lungs, throat, inner ear, and facial muscles. Therefore, practices that change or control the actions of these areas of the body can influence the functioning of the vagus nerve through the mind-body feedback loop.

According to Dr. Arielle Schwartz, you can try these from the comfort of your living room:

"Humming: The vagus nerve passes through by the vocal cords and the inner ear and the vibrations of humming is a free and easy way to influence your nervous system states. Simply pick your favorite tune and you’re ready to go. Or if yoga fits your lifestyle you can “OM” your way to wellbeing. Notice and enjoy the sensations in your chest, throat, and head.

Conscious Breathing: The breath is one of the fastest ways to influence our nervous system states. The aim is to move the belly and diaphragm with the breath and to slow down your breathing. Vagus nerve stimulation occurs when the breath is slowed from our typical 10-14 breaths per minute to 5-7 breaths per minute. You can achieve this by counting the inhalation to 5, hold briefly, and exhale to a count of 10. You can further stimulate the vagus nerve by creating a slight constriction at the back of the throat and creating an “hhh”. Breathe like you are trying to fog a mirror to create the feeling in the throat but inhale and exhale out of the nose sound (in yoga this is called Ujjayi pranayam).

Valsalva Maneuver: This complicated name refers to a process of attempting to exhale against a closed airway. You can do this by keeping your mouth closed and pinching your nose while trying to breathe out. This increases the pressure inside of your chest cavity increasing vagal tone.

Diving Reflex: Considered a first rate vagus nerve stimulation technique, splashing cold water on your face from your lips to your scalp line stimulates the diving reflex. You can also achieve the nervous system cooling effects by placing ice cubes in a ziplock and holding the ice against your face and a brief hold of your breath. The diving reflex slows your heart rate, increases blood flow to your brain, reduces anger and relaxes your body. An additional technique that stimulates the diving reflex is to submerge your tongue in liquid. Drink and hold lukewarm water in your mouth sensing the water with your tongue.

Connection: Reach out for relationship. Healthy connections to others, whether this occurs in person, over the phone, or even via texts or social media in our modern world, can initiate regulation of our body and mind. Relationships can evoke the spirit of playfulness and creativity or can relax us into a trusting bond into another. Perhaps you engage in a lighthearted texting exchange with a friend. If you are in proximity with another you can try relationship expert, David Snarch’s simple, yet powerful exercise called 'hugging until relaxed.' The instructions are to simply 'stand on your own two feet, place your arms around your partner, focus on yourself, and to quiet yourself down, way down.'

Knowing practices for self-care are important. However, it is also important to know how and when to seek out professional therapeutic help. Asking for help can often be the hardest step. You do not need to walk the healing path alone."


The risks for the VNS, include side effects for the stimulator itself and surgical risks. According to the Mayo Clinic, they are,

"For most people, vagus nerve stimulation is safe. But it does have some risks, both from the surgery to implant the device and from the brain stimulation.

Surgery risks

Surgical complications with vagus nerve stimulation are rare and are similar to the dangers of having other types of surgery. They include:

Pain where the cut (incision) is made to implant the device
Incision scarring
Difficulty swallowing
Vocal cord paralysis, which is usually temporary, but can be permanent
Side effects after surgery

Some of the side effects and health problems associated with vagus nerve stimulation can include:

Voice changes
Throat pain
Chest pain
Breathing problems, especially during exercise
Difficulty swallowing
Abdominal pain or nausea
Tingling or prickling of the skin
Slowing of the heart rate (bradycardia)
For most people, side effects are tolerable. They may lessen over time, but some side effects may be bothersome for as long as you use vagus nerve stimulation.

Adjusting the electrical impulses can help minimize these effects. If side effects are intolerable, the device can be shut off temporarily or permanently."

Tuesday, June 6, 2017

Nissen Fundoplication

A Nissen fundoplication, or laparoscopic Nissen fundoplication when performed via laparoscopic surgery, is a surgical procedure to treat gastroesophageal reflux disease (GERD) and hiatal hernia. In a fundoplication, the gastric fundus (upper part) of the stomach is wrapped, or plicated, around the lower end of the esophagus and stitched in place, reinforcing the closing function of the lower esophageal sphincter. The esophageal hiatus is also narrowed down by sutures to prevent or treat concurrent hiatal hernia, in which the fundus slides up through the enlarged esophageal hiatus of the diaphragm.

In a Nissen fundoplication, also called a complete fundoplication, the fundus is wrapped the entire 360 degrees around the esophagus. In contrast, surgery for achalasia is generally accompanied by either a Dor or Toupet partial fundoplication, which is less likely than a Nissen wrap to aggravate the dysphagia that characterizes achalasia. In a Dor (anterior) fundoplication, the fundus is laid over the top of the esophagus; while in a Toupet (posterior) fundoplication, the fundus is wrapped around the back of the esophagus.

The procedure is now routinely performed laparoscopically. When used to alleviate gastroesophageal reflux symptoms in patients with delayed gastric emptying (gastroparesis), it is frequently combined with modification of the pylorus via pyloromyotomy or pyloroplasty. (You can read that here in another blog article of mine:

This is a completed Nissen Fundoplication in Watercolors:
Source: By Dana Hamers - Own work, CC BY-SA 3.0,

This is the Nissen Fundoplication Procedure:
Source: Original Artwork by James P. Gray, M.D. 2007 (author)

The doctor that I saw that the Mayo Clinic wanted me to have this surgery done so that it would stop my vomiting. However, he concluded that since I vomit so violently, I would undo the surgery. A mom who reads my blog and has a son with gastroparesis, was nice enough to share his story with me about the Nissen he had done. When my doctor said that it would stop vomiting, he was wrong. His story is below,

"Hi, my 17 year old son had the Nissen procedure last year. He too violently throws up. The surgery went well but he said out of his 33 surgeries it was the most painful after. He went through the recovery process not realizing until about a week after that he could not even swallow water without it coming right back up.

He lost weight quickly and was very dehydrated so at his check up appointment the hospitalized him. The Nissen was too tight and nothing was going to his stomach. The doctor did a scope and stretched the area. That helped for a bit but they had to go back and stretch it a second time.

That was the last stretch they had to do. They said the Nissen would make it almost impossible for him to throw up. Boy were they wrong. He still throws up most every time he eats. By the way he has GP (gastroparesis) and has an electric stimulator in his stomach. Amanda S."

I also know a few people with gastroparesis who have had this surgery done and they are miserable now. They are unable to vomit at all. That worries me, personally, because what if you get food poisoning and need to vomit to get it out? What do you do then?

"Gastroparesis Following Nissen Fundoplication And Hiatal Hernia Repair

Nissen fundoplication with hiatal hernia repair is the most reliable and most effective treatment of GERD or acid reflux disease. The procedure is also very safe with less than 1% complication rate. Gastroparesis or delayed gastric emptying is a poorly understood medical disorder. Gastroparesis results from abnormal gastro-duodenal motility resulting in nausea, vomiting, bloating, epigastric pain and early satiety. Gastroparesis can also contribute to acid reflux disease. GERD is a multi-factorial problem and is closely related to gastric motility. Indeed, gastric fundus compliance, relaxation, food accommodation and luminal pressure affects transient lower esophageal sphincter relaxation, TLESR. TLESR is believed to be the main cause of acid reflux. It is not surprising for gastroparesis patients to suffer from heartburn and other GERD related symptoms. In fact, both GERD and gastroparesis may represent different aspects of the same problem related to esophago-gastro-intestinal dysmotility.

Many GERD patients undergoing Nissen fundoplication and hiatal hernia repair surgery may also have undiagnosed gastroparesis. Around 40% of GERD patients suffer from delayed gastric emptying. Nissen fundoplication increases gastric emptying and is sometimes associated with dumping especially in children. Wrapping the fundus around the esophagus decreases gastric compliance possibly leading to increased gastric emptying. The same mechanism of action may also be at play in the case of sleeve gastrectomy. By resecting the gastric fundus, gastric compliance decreases and emptying increases. Consequently, Nissen surgery improves gastric emptying and it contributes to gastroparesis symptom resolution.

In a minority of patients, Nissen surgery is associated with post-operative gastroparesis symptom development. These patients develop nausea, bloating, and pain in the first few days after Nissen surgery. It is unclear whether the surgery itself causes de novo gastroparesis or if it exacerbates an already existing problem with gastric emptying. It has always been assumed that vagal nerve injury results in gastric stasis and failure of the pylorus to relax. Pyloromyotomy has also been advocated in vagotomy cases. Swanstrom et al published a study in 2009 in Archives of Surgery titled “Outcomes of Nissen Fundoplication in Patients with Gastroesophageal Reflux Disease and Delayed Gastric Emptying”. He recommends the addition of pyloroplasty to Nissen fundoplication in cases of delayed gastric emptying. In my experience, pyloromyotomy, like other drainage procedures, has minimal effect on gastric emptying. Gastric emptying is a highly coordinated myo-electrical process. Many feedback signals, in addition to the vagus nerve, modulate this activity. It is unlikely that post-operative gastroparesis is the sole result of vagal nerve injury.

In 2004, a study published by Masclee et al, in the Annals of Surgery showed that laparoscopic fundoplication increases gastric emptying independent of vagal nerve function. The authors nicely showed that 10% of fundoplication patients developed vagal nerve dysfunction post-operatively without affecting gastric emptying or the efficacy of fundoplication in controlling acid reflux. The etiology of gastric stasis is following Nissen surgery remains unclear. There are no established treatment guidelines for gastroparesis. Medications, gastric pacing and drainage procedures are not effective solutions. Subtotal gastrectomy and gastric bypass are associated with poor outcomes. Longitudinal gastrectomy with or without duodeno-jejunostomy seems to be very effective in curing gastroparesis. I have developed this technique several years ago and I have had the chance to apply it on 4 patients so far. Last year, a young man with gastroparesis following fundoplication surgery at an outside institution presented to my office. I performed a longitudinal gastrectomy while preserving the fundoplication and antrum. His symptoms improved immediately. A post-operative UGI study on day one after surgery showed normal gastric emptying. The patient is 8-month post-op now and still doing great.

In summary, gastroparesis and gastric emptying remain poorly understood. However, a tailored longitudinal gastrectomy, even in the presence of a fundoplication, may be an effective and durable solution for gastroparesis. Additional studies are needed to establish this approach as the standard of care treatment for gastroparesis."


WebMD says,

"Surgery Overview

During fundoplication surgery, the upper curve of the stomach (the fundus) is wrapped around the esophagus camera and sewn into place so that the lower portion of the esophagus passes through a small tunnel of stomach muscle. This surgery strengthens the valve between the esophagus and stomach (lower esophageal sphincter), which stops acid from backing up into the esophagus as easily. This allows the esophagus to heal.

This procedure can be done through the abdomen or the chest. The chest approach is often used if a person is overweight or has a short esophagus.

This procedure is often done using a laparoscopic surgical technique. Outcomes of the laparoscopic technique are best when the surgery is done by a surgeon with experience using this procedure.

If a person has a hiatal hernia, which can cause gastroesophageal reflux disease (GERD) camera.gif symptoms, it will also be repaired during this surgery.

What To Expect After Surgery

If open surgery (which requires a large incision) is done, you will most likely spend several days in the hospital. A general anesthetic is used, which means you sleep through the operation. After open surgery, you may need 4 to 6 weeks to get back to work or your normal routine.

If the laparoscopic method is used, you will most likely be in the hospital for only 2 to 3 days. A general anesthetic is used. You will have less pain after surgery, because there is no large incision to heal. After laparoscopic surgery, most people can go back to work or their normal routine in about 2 to 3 weeks, depending on their work.

After either surgery, you may need to change the way you eat. You may need to eat only soft foods until the surgery heals. And you should chew food thoroughly and eat more slowly to give the food time to go down the esophagus.

Why It Is Done

Fundoplication surgery is most often used to treat GERD symptoms that are likely to be caused in part by a hiatal hernia and that have not been well controlled by medicines. The surgery may also be used for some people who do not have a hiatal hernia. Surgery also may be an option when:

Treatment with medicines does not completely relieve your symptoms, and the remaining symptoms are proved to be caused by reflux of stomach juices.

You do not want or, because of side effects, you are unable to take medicines over an extended period of time to control your GERD symptoms, and you are willing to accept the risks of surgery.

You have symptoms that do not adequately improve when treated with medicines. Examples of these symptoms are asthma, hoarseness, or cough along with reflux.

How Well It Works

In most people who have laparoscopic surgery for GERD, the surgery improves symptoms and heals the damage done to the esophagus.

Over time, some people have symptoms come back, have esophagitis come back, need to take medicine for symptoms, or need another operation.

Surgery can cause new and troublesome symptoms. Over time, some people have trouble swallowing, have increased flatulence (gas), and/or have trouble belching.

Risks or complications following fundoplication surgery include:

Difficulty swallowing because the stomach is wrapped too high on the esophagus or is wrapped too tightly.

The esophagus sliding out of the wrapped portion of the stomach so that the valve (lower esophageal sphincter) is no longer supported.
Heartburn that comes back.

Bloating and discomfort from gas buildup because the person is not able to burp.

Excess gas.

Risks of anesthesia.

Risks of major surgery (infection or bleeding).

For some people, the side effects of surgery-bloating caused by gas buildup, swallowing problems, pain at the surgical site-are as bothersome as GERD symptoms. The fundoplication procedure cannot be reversed, and in some cases it may not be possible to relieve the symptoms of these complications, even with a second surgery.

What To Think About

GERD can be annoying and even painful. But it is not a dangerous disease. For any GERD treatment to be worth trying, it needs to be very safe. For many people, especially those who have few problems taking medicine, surgery is not a good choice.

But when fundoplication surgery is successful, it may end the need for long-term treatment with medicine. When you are deciding between surgery and treatment with medicine, weigh the cost, risks, and potential complications of the surgery against the cost and inconvenience of taking medicine.

GERD: Which Treatment Should I Use?

Before surgery, additional tests will usually be done to be sure that surgery is likely to help cure GERD symptoms and to diagnose problems that could be made worse by surgery.

Second surgeries are harder to do, are less successful, and are more risky. So it is extremely important that the first procedure be considered carefully and be done by an experienced surgeon who is more likely to be successful the first time.

Surgery to treat GERD is rarely done on people who:

Are older adults, especially if they have other health problems in addition to GERD.

Have weak squeezing motions (peristalsis) in the esophagus. These motions are important to move food down the esophagus to the stomach. Surgery may make this problem worse, causing food to get stuck in the esophagus.

Have unusual symptoms that might be made worse by surgery.

In special cases, other surgeries such as partial fundoplication or gastropexy may be done instead of fundoplication surgery.


References and Citations:

Lundell L, et al. (2007). Seven-year follow-up of a randomized clinical trial comparing proton-pump inhibition with surgical therapy for reflux oesophagitis. British Journal of Surgery, 94(2): 198-203.

Other Works Consulted:

Galmiche J-P, et al. (2011). Laparoscopic antireflux surgery vs esomeprazole treatment for chronic GERD. JAMA, 305(19): 1969-1977.


By: Healthwise Staff
Primary Medical ReviewerAdam Husney, MD - Family Medicine
Specialist Medical ReviewerPeter J. Kahrilas, MD - Gastroenterology

Current as of November 20, 2015"

Monday, June 5, 2017

Pyloric Stent & Pyloroplasty

Pyloroplasty is surgery to widen the opening in the lower part of the stomach (pylorus) so that stomach contents can empty into the small intestine (duodenum). It is used for treatment for gastroparesis. A pyloric stent is used as a bridge between the stomach and the small intestine.


"The pylorus is a thick, muscular area. When it thickens, food cannot pass through. The surgery is done while you are under general anesthesia (asleep and pain-free).

If you have open surgery, the surgeon:

Makes a large surgical cut in your belly to open the area.

Cuts through some of the thickened muscle so it becomes wider.

Closes the cut in a way that keeps the pylorus open. This allows the stomach to empty.

Surgeons can also do this surgery using a laparoscope. A laparoscope is a tiny camera that is inserted into your belly through a small cut. Video from the camera will appear on a monitor in the operating room. The surgeon views the monitor to do the surgery. During the surgery:

Three to five small cuts are made in your belly. The camera and other small tools will be inserted through these cuts. Your belly will be filled with gas to allow the surgeon to see the area and perform the surgery with more room to work.The pylorus is operated on as described above.

Why the Procedure is Performed
Pyloroplasty is used to treat complications in people with peptic ulcers or other stomach problems that cause a blockage of the stomach opening.

Risks for anesthesia and surgery in general are:
Reactions to medications
breathing problems
blood clots

Risks for this surgery include:
Damage to the intestine
Leakage of stomach contents
Long-term diarrhea
Tear in the lining of nearby organs (mucosal perforation)

Before the procedure, tell your surgeon:
If you are or could be pregnant
What medicines you're taking, including medicines, supplements, or herbs you bought without a prescription

During the days before your surgery:
You may be asked to stop taking medicines that make it hard for your blood to clot. Some of these are aspirin, ibuprofen (Advil, Motrin), vitamin E, warfarin (Coumadin), and clopidogrel (Plavix).
Ask your surgeon which drugs you should still take on the day of the surgery.
If you smoke, try to stop. Ask your surgeon for help quitting.

On the day of your surgery:
Follow instructions about not eating and drinking.
Take the medicines your surgeon told you to take with a small sip of water.
Arrive at the hospital on time.
After the Procedure
After surgery, the health care team will monitor your breathing, blood pressure, temperature, and heart rate. Most people can go home within 24 hours.

Outlook (Prognosis):
Most people recover quickly and completely. The average hospital stay is 2 to 3 days. Most people can slowly begin a regular diet in a few weeks.

Alternative Names
Peptic ulcer - pyloroplasty; PUD - pyloroplasty; Pyloric obstruction - pyloroplasty

References: Chan FKL, Lau JYW. Peptic ulcer disease. In: Feldman M, Friedman LS, Brandt LJ, eds. Sleisenger and Fordtran's Gastrointestinal and Liver Disease. 10th ed. Philadelphia, PA: Elsevier Saunders; 2016:chap 53.

Teitelbaum EN, Hungness ES, Mahvi DM. Stomach. In: Townsend CM, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston Textbook of Surgery. 20th ed. Philadelphia, PA: Elsevier; 2017:chap 48."


"Gastroparesis: Looking at a Breakthrough

John Clarke says that a stent to bridge the stomach and small intestine may play a big role in treating patients with gastroparesis in the future.

Patients with gastroparesis don’t get a lot of good news from their physicians. Risky medications or gastric surgery have typically been the go-to solutions for people whose stomachs don’t empty properly.

Those less-than-ideal options prodded gastrointestinal motility specialist John Clarke and colleagues to a new approach: Rather than cut the pyloric valve, why not insert a stent to bridge the stomach and small intestine?

Now, results from three stent placements are promising. The write-up is soon to be published in the journal Endoscopy.

'I think this technique could potentially play a big role in the treatment of gastroparesis,' says Clarke, clinical director of the Johns Hopkins Center for Neurogastroenterology.

All of the patients that Clarke describes showed dramatic reductions in symptoms. A 15-year-old boy with chronic nausea and vomiting, for example, had endured unsuccessful trials of erythromycin, metoclopramide, domperidone and promethazine. He showed significant improvement after undergoing transpyloric stent placement. A 54-year-old man with idiopathic gastroparesis who also didn’t respond to medication experienced a complete recovery.

A third patient had minor complications that were remedied with relative ease. 'Her stent migrated out and her pain came back,' says Clarke. Things were once again fine after the team repositioned the stent.

Technically, stent placement is pretty simple, says Clarke, and the risk appears to be minimal. 'If it doesn’t work, you just take it out,' he says. 'And, as opposed to gastric stimulation, which is done through surgery, this is just endoscopy. Although this sounds a bit unconventional, its safety looks better than anything else we have.'

Clarke explains that advances in stent technology played a key role in his team’s decision to move ahead with the pyloric stents.

Recently, the field’s seen creation of a flexible, covered stent 'that you can place via the endoscope,' Clarke says. 'The stent is metallic, but covered with a silicone lining so that the mucosa won’t grow into it. The stent was approved to treat obstructions, but hadn’t yet been used to treat gastroparesis.'

The number of patients with a gastroparesis diagnosis is on the rise, Clarke says. 'I’d estimate that 30 percent of my clinical practice comprises patients with gastroparesis. And only about 30 percent of them are diabetic. Most of the patients I see have idiopathic disease.'

In the next few months Clarke expects to begin a larger trial of the stent placement.

'This is an experimental therapy, and the long-term benefits are unclear,' he explains. 'However, given the few options currently available and the risk associated with those options, endoscopic stent placement may have a key role to play in managing this complex disorder.'”

The pyloric stent is used to stretch out the pylorus so that food can pass through easier. Sometimes, balloons may be used to help stretch it out and to help spasms. The video below goes into detail about it.

"Johns Hopkins GI Doctors Use Endoscopy to Place Transpyloric Stent 'Could Play a Big Role' in Gastroparesis Treatment

Physicians at Johns Hopkins say they are encouraged by early results in three patients of their new treatment for gastroparesis, a condition marked by the failure of the stomach to properly empty its contents into the small intestine. In an article published online today in the journal Endoscopy, they describe how the placement of a small metal stent in the stomach can improve life for people who suffer from severe bouts of nausea, abdominal pain and vomiting that accompany the condition.

John Clarke, M.D., assistant professor of medicine at the Johns Hopkins University School of Medicine, and the article’s lead author, used an endoscope to place a pyloric stent in three patients with delayed gastric emptying. The pylorus is the part of the stomach that connects to the small bowel.

'I think this new technique could play a big role in the treatment of gastroparesis,' says Clarke, who also is clinical director of the Johns Hopkins Center for Neurogastroenterology. 'Though it sounds a little bit unconventional, the safety of it may be better than anything else we have out there.'

Clarke says recently developed flexible, silicone-covered metal stents have already been approved to treat some gastrointestinal obstructions, but until now have not been used to treat gastroparesis.

Typically, patients with gastroparesis don’t get a lot of good news from their physicians. Stomach surgery or risky medications such as erythromycin and metoclopramide have been the go-to treatments for the condition, which can have serious health and quality-of-life consequences.

'There are few FDA-approved options for gastroparesis patients,' Clarke says. 'The only medicines that are approved have a number of adverse effects associated with them.'

The National Institutes of Health estimates that 5 million Americans live with gastroparesis, a condition in which the contents of the stomach empty into the intestine slowly or not at all. Symptoms, including reflux, become chronic.

Using an endoscope, Clarke placed a self-expandable, coated metallic stent across the three patients’ pyloric channels, holding the channels open and allowing the patients’ stomachs to empty normally.

All three patients showed dramatic reductions in symptoms, Clarke says. One was a 15-year-old boy with chronic nausea and vomiting who had endured unsuccessful trials of erythromycin, metoclopramide, domperidone and promethazine. A second was a 54-year-old man with idiopathic gastroparesis who also didn't respond to medication, but had complete recovery after his stent placement. In a third patient, the stent migrated out of place and her pain came back, but after replacing it, the pain eased, Clarke reports. All were treated at The Johns Hopkins Hospital.

Clarke says the stent placement procedure isn't difficult.

'Technically it’s pretty simple, and the risk appears to be minimal; if it doesn’t work, you just take it out,' he says. 'Gastric surgery to stimulate emptying is riskier than endoscopy.'

The number of patients diagnosed with gastroparesis is on the rise, Clarke says. 'I’d estimate that 30 percent of my clinical practice comprises patients with gastroparesis.'

Clarke says a larger clinical trial, which he expects to begin in the near future, is needed to provide longer follow-up of results and to identify which patients are likely to benefit the most from stents. “Our hope is that stent placement may become either a primary treatment option or a bridge technology to determine who can best benefit from surgery to improve stomach emptying.”

Endoscopic Treatment of Gastroparesis
Thomas R McCarty and Tarun Rustagi

Gastroparesis has traditionally been a largely medically managed disease with refractory symptoms typically falling under the umbrella of the surgical domain. Surgical options include, but are not limited to, gastrostomy, jejunostomy, pyloromyotomy, or pyloroplasty, and the Food and Drug Administration approved gastric electrical stimulation implantation. Endoscopic management of gastroparesis most commonly involves intrapyloric botulinum toxin injection; however, there exists a variety of endoscopic approaches on the horizon that have the potential to radically shift standard of care. Endoscopic management of gastroparesis seeks to treat delayed gastric emptying with a less invasive approach compared to the surgical approach. This review will serve to highlight such innovative and potentially transformative, endoscopic interventions available to gastroenterologists in the management of gastroparesis.

Keywords: Botulinum, Gastrojejunostomy, Transpyloric, Pyloromyotomy, Gastric stimulator, Gastric pacemaker, Stenting
Core tip: Although a majority of gastroparesis patients respond to medical treatment, patients with refractory symptoms pose a therapeutic challenge and are often referred for surgical management. Endoscopic management of gastroparesis seeks to treat delayed gastric emptying with a less invasive approach compared to the surgical approach. Endoscopic treatment of gastroparesis most commonly involves intrapyloric botulinum toxin injection; however, there exists a variety of endoscopic approaches on the horizon that have the potential to radically shift the standard of care for refractory patients.

Gastric emptying is a highly regulated, carefully choreographed process that demands a harmony of synchronized impulses working together as an impetus for which food can be delivered distally down the gastrointestinal tract. These propulsive forces are generated by proximal fundic tone, the interstitial cells of Cajal, distal antral contractions, and relaxation of the pyloric sphincter to create a scripted peristalsis[1]. Gastroparesis, or delayed gastric emptying, is characterized by physiologic disturbances in antral hypomotility, increased gastric outlet resistance, and pyloric dysfunction without evidence of obstruction[2,3]. Patients typically present with dyspepsia-like symptoms including early satiety, postprandial fullness, bloating, nausea, vomiting, and abdominal pain[2,4-6]. The most common etiologies of gastroparesis are idiopathic, diabetic, or post-surgical[2,7].

The epidemiology of gastroparesis is not well known though a small population-based study showed a prevalence in men and women of 9.6 and 37.8 per 100000 persons and an age-adjusted incidence of 2.4 and 9.8 per 100000 person-years, respectively[8]. Gastric-emptying scintigraphy is the gold standard for the diagnosis of gastroparesis and consensus recommendations for the procedure involve 99-m technetium sulfur-colloid labeled low fat, egg-white meal with imaging at 0, 1, 2, and 4 h[9]. The diagnosis of delayed gastric emptying is confirmed if there is > 90% gastric retention at 1 h, > 60% at 2 h, > 10% at 4 h[9,10]. Small, frequent meals along with medical therapy including prokinetic agents, such as dopaminergic (D2) antagonists - metoclopramide and domperidone, or motilin-analogue - erythromycin, are the first line of treatment.

The majority of data regarding the efficacy of conventional prokinetic agents for the treatment of gastroparesis is outdated[11-15]. It has been approximately 30 years since the first randomized controlled trials of the conventional prokinetic agents, metoclopramide, domperidone, and erythromycin, have been published, and despite this, they are still first-line agents for the treatment of gastroparesis[16]. Metoclopramide has been the most extensively studied and has been associated with less improvement in gastric emptying when compared to erythromycin[15]. A meta-analysis assessing benefits of four different drugs in 514 patients in 36 clinical trials reported the macrolide antibiotic erythromycin as the most potent stimulant of gastric emptying, while erythromycin and the dopamine receptor antagonist domperidone (not available in the United States) are best at reducing symptoms of gastroparesis[17]. Currently, several novel pharmacotherapies such as ghrelin receptor agonists (TZP-101, TZP-102, RM-131), mitemcinal, prucalopride, velusetrag, levosulpiride are in development, though their clinical efficacy and safety remains to be established[16,18,19]. While it is generally accepted that a significant percentage of patients require additional therapy beyond prokinetic agents, no clear data exists to determine the percentage of patients who fail medical management.

Patients with symptoms refractory to medical therapy pose a therapeutic dilemma. Patients are often referred for surgical treatment including a variety of potential procedures not limited to gastrostomy, jejunostomy, pyloromyotomy, pyloroplasty, and gastrectomy to improve gastric emptying. Poor and sometimes unpredictable response, in addition to the morbidity and mortality of surgical interventions, has led to the emergence of endoscopic therapies in management of gastroparesis (Table ​(Table1).1). While frequently under-utilized, endoscopic treatment strategies are at the cusp of altering traditional standard of care with exciting new developments that have the potential to radically shift the preferred management of refractory gastroparesis.

Endoscopic intrapyloric botulinum toxin injection (IPBI) is the most studied and perhaps the most commonly employed endoscopic treatment for those suffering from refractory gastroparesis, though this therapy still remains highly controversial. Botulinum toxin is a potent inhibitor of neuromuscular transmission used more commonly for the treatment of spasm in gastrointestinal sphincters. Botulinum toxin injection into the lower esophageal sphincter (LES), with or without endoscopic ultrasound (EUS)-guidance, is an established safe and effective therapy for management of achalasia in high-risk surgical patients. Low dose injection of botulinum toxin in the pylorus muscle decreases contractility secondary to decreased acetylcholine release by irreversibly binding to cholinergic receptors and directly affects muscle tone at higher doses[20]. The toxin also reduces substance P immuno-reactivity and disrupts pyloric myoelectric activity[21,22].

The procedure involves endoscopic access to the patient’s pylorus with injection typically in a radial pattern at or within 2 cm of the pylorus, with a total dose of 100 to 200 units[23]. There is an alternative hypothesis that antroduodenal or pyloroduodenal manometry may be helpful to evaluate the baseline pylorus muscle tone to determine the best site for IPBI to predict response; however, this warrants further investigation[24]. The usual duration of benefit from IPBI ranges from 1 to 5 mo at which time worsening symptoms can be re-treated with repeated injections[23,25]. It is important to note however, that the effect of IPBI may not be limited simply to the pyloric muscle as there have been rare reports of gastric and intestinal absorption leading to peripheral neuromuscular blockade[26]. Despite this, the procedure is typically well tolerated and safe. There are a multitude of open-label studies in adults with gastroparesis (regardless of cause - idiopathic, diabetic, and post-surgical) reporting an improvement in symptoms and gastric emptying after endoscopic IPBI[25,27-31]. The largest observational study including 63 patients by Bromer et al[25] documented a 43% response rate to botulinum toxin treatment lasting a mean of approximately 5 mo.

While observational data suggests that botulinum toxin injections reduce symptoms and accelerate gastric emptying in both idiopathic and diabetic gastroparesis, 2 independent, double-blinded, randomized controlled studies have shown little to no improvement in gastric emptying and no symptomatic improvement compared with placebo[32]. Friedenberg et al[33], using a randomized, double-blind, placebo-controlled trial, explored whether botulinum toxin improves symptoms to a significantly greater extent than placebo. In this study, 32 patients were randomized to botulinum toxin or placebo with 1-mo follow-up post endoscopic procedure measuring gastric retention at 2 and 4 h and symptoms based upon 2 validated scoring systems - the Gastroparesis Cardinal Symptom Index (GCSI) and the Gastroparesis Visual Analog Scale (GVAS). While endoscopic botulinum toxin injection did improve gastric emptying rates, the benefit was not superior to placebo at 1 mo (67% vs 64% at 2 h, P = 0.56 and 29% vs 28% at 4 h, P = 0.86, for IPBI vs placebo respectively). Additionally, there was no significant difference or improvement of symptoms between IPBI compared to the placebo (GCSI - 34.4 vs 36.4, P = 0.21; GVAS - 603 vs 584, P = 0.68, respectively). Another randomized-controlled crossover study including 23 patients, predominantly with idiopathic gastroparesis, also reported similar results, with no significant benefit of endoscopic injection of botulinum toxin over placebo in improving either symptoms or rate of gastric emptying[34].

This discrepancy between open-label and randomized controlled studies may be related to dose of toxin injected and patient population selected. In a retrospective cohort study of 179 patients by Coleski et al[23], patients treated with 200 units achieved a greater improvement in gastroparetic symptoms 1 to 4 mo post intervention compared to those treated with 100 units (76.7% vs 54.2%, P = 0.02). On multivariate analysis female gender, age < 50 years, and a non-diabetic or post-surgical etiology of gastroparesis were found to be associated with a significant response to therapy in this study. While the use of botulinum toxin remains highly controversial, the American Gastroenterological Association (AGA) currently does not recommend the use of endoscopic IPBI for patients with gastroparesis[35]. However, given the small sample size of existing studies with conflicting data, there is an eminent need for larger randomized trials in the future before a definitive decision or treatment guidelines can be concluded.

In 2000, gastric electrical stimulation (GES) was approved by the United States Food and Drug Administration (FDA) as a humanitarian device exemption in patients with refractory symptoms of diabetic or idiopathic gastroparesis[36]. Often referred to as a gastric pacer, GES uses an implantable device consisting of a pulse generator that allows for electrical stimulation at a variety of frequencies. Permanent GES for gastroparesis, typically 6 cm x 5.5 cm x 1 cm, requires a lengthy surgical implantation under general anesthesia. Several case series and small randomized controlled trials, the most important being the Worldwide Anti-Vomiting Electrical Stimulation Study (WAVESS), have shown clinical benefit from GES[37-43]. A subsequent meta-analysis by Chu et al[44] in 2012 confirmed significant improvement in symptom severity and gastric emptying times, though many of the analyzed studies were low quality observational studies lacking control groups. A more recent study by McCallum et al[40] also demonstrated improvement in weekly vomiting frequency amongst all patients with idiopathic gastroparesis with a median reduction of 61.2%. The National Institute of Health and Care Excellence issued guidelines in 2014 that stated current evidence is adequate to support the use of GES[45].

As of 2012, surgery was the only means available to implant the GES device. Although endoscopic placement of temporary gastric stimulators has been proven as a concept and is often used to determine whether a patient will respond to GES before undergoing a permanent implant surgery, the lack of a permanent endoscopic solution and the reliance on future surgery for symptomatic improvement has limited further endoscopic utilization at present[46,47]. However, Deb et al[48] has designed 5 innovative endoscopic gastric implantation techniques and developed a novel, wirelessly powered miniature gastrostimulator. While this early model was conducted in pig studies with no human data or patient trials, the study provides an important prototype for other dysmotility treatment paradigms and provides exciting new options that may translate in the future to less invasive endoscopic placement in gastroparetic patients. This miniature wireless GES device for endoscopic implantation can be easily inserted into the stomach through an over-tube with 2 GES electrodes endoscopically attached to the gastric mucosa and secured with endoclips[49]. Electro-gastrogram recordings have demonstrated that gastric slow waves become more regular with constant amplitudes when stomach tissues are stimulated, in comparison with no stimulation. The frequency-to-amplitude ratio also changes significantly with stimulation[49].

The miniature gastrostimulator and its attachment techniques have the potential to fundamentally shift the approach to refractory gastroparesis and provide a means for endoscopic implantation of gastric stimulator. Although further studies are required to prove the efficacy of such device, if shown to be effective, the possibility of FDA approval given a similar precedent set by GES would provide a clear indication for endoscopic management. The endoscopic gastric implantation device and technique may decrease the need for surgical implantation of GES and revolutionize the preferred management of refractory gastroparesis.

A novel approach recently described by Clarke et al[50] at Johns Hopkins involves the use of through-the-scope transpyloric stent placement as a treatment for gastroparesis. In this small case series (n = 3), double-layered, fully-covered Niti-S self-expandable metallic stents (TaeWoong Medical, Seoul, South Korea) were used to successfully improve symptoms of gastroparesis. The procedure entails the placement of a self-expandable stent across the pyloric channel, deployed under endoscopic guidance without fluoroscopy. The stent is then fully deployed in the transpyloric position with its proximal end in the gastric antrum. Case 1 involved a 23-year-old woman with diabetic gastroparesis; case 2, a 15-year-old boy with chronic nausea and vomiting with markedly abnormal gastric emptying study; and case 3, a 45-year-old man with idiopathic gastroparesis. In all 3 cases, patient symptoms markedly improved or became asymptomatic at 115 d, 122 d, and 174 d follow-up respectively. While this includes only a case series of 3 patients, the stark improvement and lasting results at follow-up after the procedure suggest that transpyloric stent placement improves symptoms associated with impaired gastric emptying[50].

A major concern with transpyloric stenting is stent migration leading to recurrence of symptoms. Several stent securing methods such as endoscopic clips [through-the-scope clip (TTSC) and over-the-scope clip (OTSC)] and endoscopic suturing (ES) have been described to reduce stent migration. Despite the numerous options available, the question remains which stent securing method is superior. In a small case series by Saxena et al[51], transpyloric stent placement and fixation was performed in patients with refractory gastropariesis. The stent was anchored to the antral mucosa with either no device, TTSC, OTSC, or ES. A total of 17 patients underwent 28 transpyloric stent placements with 100% success rate regardless of method. Stent migration occurred as expected in 100% of those with no device; however stent migration was significantly lower in the ES vs TTSC group (16.7% vs 100%, P = 0.02). Stent migration occurred more frequently in the OTSC placement group as compared to the ES group (52.9% vs 16.7%, P = 0.075). With this data, albeit limited due to the number of the patients studied, there is evidence for concern regarding stent migration with transpyloric stent placement; however, it appears this can be minimized with OTSC and endoscopic suturing.

Currently, future studies are required to truly ascertain the long-term durability, utility, and preferred method for transpyloric stenting and fixation. Until that time, transpyloric stenting will remain a limited option for endoscopists in the management of patients with refractory gastroparesis.

Rao et al[52] demonstrated that phasic motor activity in the antrum and duodenum can be stimulated by fundic balloon distention. While there are no such studies to determine the effect of pyloric channel distention on the interstitial cells of Cajal in the stomach or gastric emptying, endoscopic pyloromyotomy and manipulation of the pylorus may improve gastroparesis refractory to medical management. With this notion of distention or disruption of the pylorus to improve gastroparetic symptoms, Khashab et al[53] demonstrated the feasibility and efficacy of this approach with a case report of the first human gastric peroral endoscopic myotomy (G-POEM) in a patient with severe refractory gastroparesis. The procedure was well tolerated with vast improvement in gastroparetic symptoms noted at 12-wk follow-up.

This technique is similar in principle to the submucosal dissection and myotomy performed for the treatment of achalasia[54]. Techniques through a submuscoal tunnel were first described in animal models by Pasricha et al[55] in 2007. Endoscopy is performed and involves myotomy of the inner circular and oblique muscle bundles 2-5 cm proximal to the pylorus on the anterior wall of the stomach, preserving the longitudinal muscle layers with larger vessels in the submucosa coagulated. This is then followed by endoscopic pyloromyotomy by dissecting the pylorus until deeper layers become evident with full separation of the pyloric ring[54,56].

In another study by Shlomovitz et al[56], endoscopic pyloromyotomy was performed in 7 female patients with early follow-up suggesting promising symptomatic improvement in 6 of the 7 and normal gastric emptying studies at 4 h noted in 4 of the 5 patients. One patient that did not respond subsequently underwent laproscopic pyloroplasty. Complications included gastrointestinal bleeding in one patient 2 wk after the procedure and pneumonia. Despite these complications, this endoluminal pyloromyotomy technique could provide an incision-less, less invasive alternative with similar functional outcome as compared to standard laparoscopic pyloroplasty[56]. While the small number of cases certainly limits the ability to determine the true impact of this procedure in the management of gastroparesis, with more frequent use, increasing technical experience, and more data, endoscopic pyloromyotomy has exciting potential to be at the forefront in the endoscopic management of gastroparesis.

Enteral nutrition and feeding is sometimes required for more severe symptoms and can be seen in up to 30% of grade 3 gastroparesis[57,58]. Direct percutaneous endoscopic jejunostomy (DPEJ) is a push enteroscopy technique that was first described by Shike et al[59], and offers another approach to provide direct postpyloric enteral nutritional support. Percutaneous endoscopic jejunostomy (PEJ) is a safe and effective means to palliate malnutrition in patients with severe gastroparesis[60,61]. Maple et al[62] demonstrated, in the largest cohort study to date, clinical outcomes with DPEJ and included 307 attempts at PEJ placement with a success rate of 68%. While this study included multiple indications for DPEJ placement, gastroparesis was a substantial proportion (n = 61 or 21%). A case series by Toussaint et al[63], showed a PEJ technical success rate of 78.6% with no immediate complications reported; however, this was based upon a small sample size of 14 patients total. Based on these data, PEJ should be considered in the algorithm of enteral access for nutritional support before jejunostomy is considered.

The main limitation of DPEJ is technical difficulty as the jejunum is narrow, making it more difficult to advance a needle directly into the lumen[64]. This difficulty can be alleviated with balloon-assisted enteroscopy (BAE)[65]. Aktas et al[66] reported the first prospective study in which single-balloon enteroscopy (SBE)-assisted DPEJ was successful in 11 of the 12 procedures (92%). In this prospective case study, SBE was shown to facilitate the identification of an ideal DPEJ insertion site for the placement of a direct percutaneous jejunal feeding tube. While again this study is limited in size, the results were similar to previous small case series using double-balloon enteroscopy (DBE)-assisted DPEJ placement[65,67].

While surgical gastrojejunostomy is a potential treatment option for patients with gastroparesis, the procedure is associated with substantial morbidity and mortality when patients are in less than ideal clinical condition[68-71]. Fritscher-Ravens et al[72,73] and Binmoeller et al[74] first described EUS-guided gastrojejunostomy in pigs by using a compression button and lumen-apposing metal stent, respectively. These studies were built upon the success of previous studies - notably Cope et al[75] creating the first transluminal anastamosis using self-expanding metal stents (SEMS) and Chopita et al[76] reporting the first clinical trial using fully covered version of the flared stent. While the Fritscher-Ravens et al[72,73] and Binmoeller et al[74] studies were performed as possible alternatives to surgical bypass for the palliation of malignant gastric outlet obstruction, more benign conditions such as gastroparesis may potentially benefit from this transluminal therapy.

An additional study performed by Itoi et al[77], developed a new enteric tube that allowed for the entrapment of fluid between the double balloons without the need to use tissue-opposing devices such as tilt tags. This maintains distention of the small bowel between the double balloons at the initial FNA needle puncture site. Although simply a pilot study, all stents, with exception of one stent, were successfully deployed without complication. All animals showed normal eating behavior without signs of infection at 1-mo follow-up post procedure. Endoscopic gastric imaging showed patent stents in all pigs. While this study lacks power, the initial findings are impressive. The development of a EUS-guided gastrojejunostomy appears to be promising as a minimally invasive treatment.

Although surgical gastrojejunostomy has been shown to improve gastroparetic symptoms, EUS-guided gastrojejunostomy warrants further investigation owing to unknown long-term stent safety and patency issues[74]. Ideally, the stent can be removed after an interval of time, leaving a permanent fistula tract. However, studies are needed to determine the necessary pressure gradient and initial gastrojejunostomy tract diameter in order to maintain long-term fistula patency after stent removal. The minute amount of data available to date, while optimistic and potentially transformative, requires repeat analysis and trials with human study before implementation into the gastroenterologist’s everyday arsenal. However, given the technical success of studies above, the future of endoscopic gastrojejunostomy using EUS-guided lumen-apposing metal stents is bright with the potential to diminish the need for invasive surgeries and improve symptoms of gastroparesis refractory to medical management.

In summary, there is a wealth of potential endoscopic approaches that may one day be at the disposal of endoscopists. While many of these procedures and pioneering approaches have the potential to be ground-breaking and radically transform the standard management algorithm of refractory gastroparesis, all of them require more studies to validate, corroborate, and substantiate early optimistic data. The opportunities for less invasive endoscopic treatment of gastroparesis are abundant and inspiring. From further studies to evaluate the true effectiveness of IPBI to the potential for EUS-guided lumen-apposing metal stents for gastrojejunostomy, the role of endoscopic therapies in management of gastroparesis is likely to expand in near future."