Things You Need to Know

Gastroparesis is a chronic stomach disorder in which the emptying is delayed without a blockage.  The symptoms associated with it include nausea, vomiting, bloating, fullness, and decreased appetite.  The stomach contents, including food and medication, can remain for up to a few days, and later may be seen undigested in the patient’s vomit.   

The most common causes are Diabetes (30%) and Idiopathic (35%). In diabetes, an excess of glucose causes damage to the nerves of the stomach, thereby preventing the muscles from pushing the food into the intestines for digestion.  Idiopathic Gastroparesis means the cause is unknown.  Doctors have hypothesized that the cause could be viral, surgical, or trauma but a definite cause is usually never established.

The first treatment for patients with gastroparesis is to modify the diet.  This includes avoiding fried, acidic, spicy, sugary, or high-fiber foods.  These can irritate the stomach and lead to increased pain and bloating.  In addition, anti-nausea medications like Zofran or Phenergan can be used.  Anti-nausea medications can manage the symptoms but will not increase the stomach emptying speed.  Two medications called Erythromycin and Reglan can increase the stomach emptying speed, however they have frequent side effects.  Erythromycin CAN be associated with heart arrhythmias and Reglan (Metoclopramide) CAN cause permanent twitches and tremors. 

If symptoms continue despite medication and diet modification, patients become candidates for the gastric stimulator.  The stimulator works via two mechanisms. 1. It slowly stimulates the muscles of the stomach to improve emptying.  2. The stimulation of adjacent nerves inhibits nausea signals to the brain.  The stimulator is indicated to treat symptoms of nausea and vomiting.  The bloating, fullness, and improvement in appetite can occur over time as the muscles improve emptying.

The gastric stimulator has 2 parts: 2 leads placed into the muscle layer of the stomach and a battery/stimulator in the abdominal wall fat. The leads travel through the abdominal wall to the stomach. The surgeon will then locate the stomach and place the leads into the muscle in the wall of the stomach at the point responsible for the movements of the stomach. 

Most surgeons use a 5-7 inch midline incision to accomplish the placement. Dr. Wishnew used to be one of the leading surgeons in Enterra Gastric stimulator placement using the robot (a small camera with small incisions). She now manages current implanted stimulators but no longer implants.

During the surgery, the stimulator is turned on, but the maximal effect will take 6 weeks. Also, the anesthesiologist will inject a long-acting numbing medicine that lasts around 72 hours.

The maximal effect of gastric stimulation is felt after 4-6 weeks. For this reason, we wait after placement and after each adjustment to see how much improvement is seen. The doctor (maybe a GI or surgeon) will place the programmer on your skin over the device and may make adjustments on the screen. There are several variables to adjust and an algorithm is established depending on the response to nausea and vomiting. The goal is NOT a cure; there is no cure for gastroparesis. The goal is 70-80% reduction in symptoms and cessation of all medication related to nausea/vomiting. Once this goal is met, the visits can become less frequent.

Before your surgery, Dr. Wishnew will explain the procedure to you but be sure to ask her any questions you may have. You may be asked to sign a consent form that gives permission for the procedure. Read the form carefully and ask questions if anything is not clear. Dr. Wishnew will ask questions about your past health and also give you a physical exam as this is to make sure you are in good health before the procedure. You may also need blood tests and other diagnostic tests. You must not eat or drink for 8 hours before the procedure. This often means no food or drink after midnight. Be sure to tell Dr. Wishnew if you are pregnant or think you may be pregnant, if you are sensitive to or allergic to any medicines, latex, tape, and anesthesia medicines (local and general). Dr. Wishnew will need to know about all the medicines you take. This includes both over-the-counter and prescription medicines. It also includes vitamins, herbs, and other supplements. Some you may still take with a sip of water, so be sure to ask if your medication is this type. Tell Dr. Wishnew if you have a history of bleeding disorders and let her know if you are taking any blood-thinning medicines, aspirin, ibuprofen, or other medicines that affect blood clotting. You may need to stop taking these medicines before the procedure. If this is an outpatient procedure, you will need to have someone drive you home afterward. You won’t be able to drive because of the medicine given to relax you before and during the procedure. Follow any other instructions Dr. Wishnew gives you to get ready.

To have the best outcome and the least pain--WALK!

Walking will:

• Reduce the cramping of your abdominal muscles and reduce pain
• Encourage your intestines to move
• Relive gas pains
• Reduce blood clot risk, which is increased after surgery for 10-14 days.

Your daily restrictions include:

• No driving while taking pain medications
• No lifting greater than 20 lbs until you see Dr. Wishnew again
• You may return to work as long as the directions above can be followed at work.

Diverticulosis reflects a non-inflamed colon with outpouchings, similar to a bubble in a tire. Diverticulitis indicates these outpouches and the surrounding colon are irritated or infected (known as inflammation). The reason the colon develops these outpouchings is primarily because of how Americans eat. We tend to eat fairly high protein and low fiber (ie minimal vegetables). Because of this practice, our stool is very dense and firm, requiring the colon to exert extra effort to push it along and out of our bodies. This excess pressure causes the colon wall to balloon out and cause diverticula. Stool can get caught in these openings and cause an infection, or Diverticulitis.
Most of these infections can be treated with antibiotics and do not require surgery. Sometimes the diverticuli develop a hole allowing the infection or even some stool to leak out. This will require antibiotics and the colon to be removed, either emergently or in 6 weeks depending on the severity.

Diverticula are permanent once they are formed and no treatment can prevent complications from this disease. However, certain diets can help prevent the formation of further diverticula and keep you healthy and control symptoms. Diverticulitis can be prevented if a person gets regular exercise, drinks plenty of water, and eats a diet rich in high-fiber foods such as fresh fruits, whole grains, and vegetables. Drinking lots of fluids is necessary with a high-fiber diet to keep stools soft. These high-fiber diets prevent constipation and therefore the formation of diverticula or worsening of the condition. The foods you eat must make stools soft, large, and easy to pass without any strain. This is why doctors suggest that people avoid corn, nuts, berries, and seeds that can block diverticular openings and lead to diverticulitis. These foods contain hulls that can get caught in the diverticula, block, and cause pain. Other foods to avoid are coarse grains, coconut, peas, beans, tomatoes, pickles, strawberries, dried fruits, and cucumbers. Remove skin from vegetables and fruits before eating. Excess intake of tea, coffee, and alcohol must be avoided. All these foods and beverages increase constipation symptoms. Do not take too many laxatives to encourage regular bowel movements. Eating at regular times, drinking lots of fluids, and eating the right foods encourage healthy bowel habits and keep symptoms of diverticulitis under control.

Unless Dr. Wishnew says otherwise, showering normally with soap and water is the best way to care for your incision. Remember to remove your dressing before surgery and if the wound is draining, replace the dressing. The use of alcohol, betadine, or hydrogen peroxide is not necessary and will impair wound healing. Also, using triple antibiotic ointment is not necessary. If the wound becomes warm, red, firm, enlarges, or drains, please call Dr. Wishnew’s office immediately. Bruising or yellow discoloration is normal. Also beneath the incision, there may be a hard ridge of tissue that will resolve over 6 weeks.

Normal post-operative pain is controlled with prescription pain medications such as Norco (Tylenol/hydrocodone), Tylenol with codeine, and Ultram. For temporary worsening of the pain, Ibuprofen can be taken with Norco or Tylenol #3. These two medications are synergistic and will boost each other’s pain-relieving capability. Do not take Tylenol in while taking Norco or Tylenol #3, as they already have Tylenol in them. You may, however, take Tylenol instead of prescription pain medications. Gas pains can also cause pain. The best way to get rid of gas is to walk approximately 5-10 minutes every few hours while awake. If the pain is in the right shoulder, this is also a gas pain from the air we place inside the abdomen during laparoscopic surgery. Walking and taking over-the-counter Gas-X can help this as well. The most common cause of postoperative pain is CONSTIPATION. Due to the anesthesia and pain medications, you may go several days without a bowel movement. Dr. Wishnew generally recommends trying to have a bowel movement daily after surgery. She recommends Colace stool softeners once to twice a day. If constipation continues, try a laxative of your choice or a full bottle of Magnesium Citrate.