Repeated Gastric Pacemaker Lead Migration and Gastric Wall Perforation

Abstract

Gastric Neurostimulators are increasingly used to treat gastroparesis, but can lead to complications including lead device or migration and perforation. To our knowledge, this is the first case report with repeated gastric wall perforation in the same patient. A 31 year old woman with idiopathic gastroparesis s/p gastric neurostimulator placement in 2007 presented for evaluation of a nonfunctioning device due to a low-charge battery, complicated shortly after by acute onset severe midepigastric abdominal pain for one day. Upon admission, a CT scan revealed that one of the device leads was protruding into the lumen of the stomach, penetrating the gastric wall. The patient underwent a diagnostic laparoscopy with removal of the displaced lead and installation of a new Enterra II gastric neurostimulator, with immediate resolution of her symptoms. However 8 months later the patient again experienced abdominal pain, and repeat abdominal CT scan showed recurrent lead penetration into the gastric lumen. She underwent repeat surgical intervention for permanent explant of the device given overall improvement of her symptoms. Patients with gastroparesis can have significant debilitation due to nausea, vomiting, dehydration and weight loss. Although the etiology is often unknown, it commonly affects diabetic or postsurgical patients and is thought to be due to impaired gastric nerve function failing to stimulate smooth muscle leading to decreased contractility1. When medical therapy with diet modification and pharmaceuticals fail, patients can undergo placement of a gastric neurostimulator, which is a small generator implanted underneath the abdominal skin with electrodes placed into the greater curvature of the stomach. Although many patients report improvement in gastric emptying and symptoms, complications including lead or device migration, implant pocket hematoma or infection can occur between 5-14% of cases.2 These often require surgery, and it is unclear how often these complications recur. It is important for clinicians to be aware of the potential long term risks of gastric neurostimulator placement as these devices come of age.