Home » Gastroparesis »
Treatment options
Gastric stimulation
More than 2,500 placed — more than any surgeon in the world. What the device does, how it is placed and adjusted, and who it helps.
If your gastroparesis is nausea and vomiting — without bloating, fullness, or pain — then your stomach isn’t under pressure. Decompressing it won’t help you. What you need is to quiet the nerve that is generating the nausea.
That is what a gastric stimulator does.
Dr. Hughes has placed more than 2,500 gastric stimulators, more than any surgeon in the world. He also trains and advises other surgeons on placement and management on behalf of Enterra Medical, the device’s manufacturer.
What it is — and what it isn’t
It’s not a pacemaker. It doesn’t sense what’s going on in your stomach and respond to it.
A cardiac pacemaker monitors and reacts. A gastric stimulator doesn’t. It runs at fixed settings and delivers a steady stream of energy to the stomach wall, which prompts the stomach’s pacemaker cells to signal the nerves and muscle in a more coordinated pattern.
It has not been shown to reliably make the stomach empty faster. Which is a genuine irony, since emptying speed is how gastroparesis is diagnosed. What it is good at — reliably, in the right patients — is shutting down the nausea and vomiting.
This is established treatment. The device received FDA approval in 2000. Twenty-five years of use is not experimental.
The two parts
The generator is about the size of a cardiac pacemaker. It sits under the skin, to the right of the navel. It is battery powered and not rechargeable — on the lowest settings it lasts roughly 15 to 20 years, and 8 to 10 years on average once adjustments are factored in. When the battery is depleted, the generator is swapped for a new one and set back to the settings that were working for you.
The leads carry the energy from the generator to two bare electrodes embedded in the stomach wall. Unlike the generator, the leads are permanent — unless they break, erode into the stomach, or accumulate enough scar tissue over the years that the settings required climb too high.
The current Reliastim leads have half the electrical resistance of the previous generation, which roughly doubles battery life. That is why the timelines above are longer than figures you may find elsewhere.
There is one of these in the clinic. Patients hold it before deciding. On a phone screen it looks small and on a monitor it looks enormous, and neither is accurate — it’s easier to just pick it up.
On MRI: the Enterra system has been MR Conditional since FDA approval in October 2023, meaning MRI scans of the head, neck, arms, and legs can be done under specified conditions. Scans of the chest and abdomen are not covered, and the current leads do not change that. Enterra publishes the full conditions in its MRI guidelines for patients.
There is only one manufacturer. There is no comparison shopping to be done here.
How it’s placed
The operation is laparoscopic, takes about an hour to an hour and a half, and you go home the same day.
Through two or three small laparoscopic incisions, the electrodes are placed into the muscle of the stomach wall and sutured, with small discs to secure them. One further incision to the right of the navel — two to three inches — creates the pocket for the generator. The leads plug into it and are tightened down with four small bolts.
Two details that make a difference afterward:
The generator is anchored. Two stitches secure one side of it to the tendon over your abdominal muscles. It can still move as you move — patients describe it as flipping — but it can’t spin. A generator that spins coils the wires behind it, and coiled wires crack.
The leads are covered. Patients commonly report pain under the left ribs after a stimulator. Dr. Hughes takes a layer of fat, lays it over the leads, and sews it down so they can’t rub against the ribs. His patients therefore do not get that pain.
The step most practices skip
During placement, a small wedge of stomach wall is removed with a stapler and sent to pathology, where the remaining pacemaker cells, nerve cells, and muscle are counted.
That number is not academic. It cannot be seen by eye, and it does not show on an X-ray. It tells Dr. Hughes how much functional tissue you have left, which tells him how to adjust your device.
- Badly damaged stomach → titrate more aggressively, so it takes less time and fewer office visits to feel better.
- Better preserved stomach → titrate more gently, so you don’t deplete the battery as quickly.
Two patients with identical symptoms can need entirely different approaches to the same device. The pathology is how you tell which one you are.
Adjusting the device
The stimulator starts on the lowest settings, to preserve battery life.
From there it’s adjusted in clinic one month after surgery, then every three months until the nausea is controlled or gone. Nothing is cut — the programmer is laid on top of your skin. Once you reach settings that work, they stay put until the battery runs out.
Follow-up is at one month and three months, then roughly every three months until things are stable, then yearly. Adjustment visits are in person; check-in visits can be telehealth.
Who this operation is for
The decision is made on symptoms.
Gastric stimulation is the right operation if your symptoms are nausea and vomiting without significant bloating, fullness, or upper abdominal pain. There’s no pressure problem to solve, and a pyloroplasty wouldn’t address what’s wrong.
If you do have bloating, fullness, and pain, the stimulator is the second step, not the first. Pyloroplasty comes first, and about two in three patients never need the stimulator at all.
Why the order matters
Dr. Hughes originally did it the other way around: stimulator first, and a feeding tube if that failed. When he began performing pyloroplasty on patients who already had stimulators, those patients did better on markedly lower settings. Some no longer needed the device at all. He reversed the sequence.
Patients who have had a pyloroplasty respond better to the stimulator and need less energy to get there.
After a pyloroplasty, the wait is at least three months — the pyloroplasty isn’t fully open before then, and there’s no way to judge what nausea remains until it is.
Recovery
Home the same day. Stitches are under the skin and dissolve; there is nothing to remove. Dressings come off after a week.
Activity: nothing over 10 pounds for two weeks. Showering is fine; don’t submerge the incisions for two weeks.
Pain varies enormously. Some patients report almost none, and some describe the worst pain of their lives. There is no predicting which you’ll be. With Journavx, the non-narcotic pain medication now used at Vanguard, pain is much better controlled without the side effects narcotics bring — worsening nausea, vomiting, and constipation.
The generator will start to move, usually about a month after surgery. As the tissue around it softens, it can feel like it has come loose. It hasn’t. That is what it is supposed to do.
Risks, stated plainly
Infection is the main concern, and the most common problem. Now that Dr. Hughes places these primarily at outpatient surgical centers, the infection rate is about 5%. Two weeks of oral antibiotics usually clears it. Roughly one case in 100 needs a washout in the operating room. Roughly one in 200 requires removing the device.
Left-sided pain from the leads pressing upward. Usually this tracks with worsening bloating — the treatment is generally to turn the stimulator up, which reduces the bloating, which resolves the pain.
Pain at the anchor point. Some patients don’t tolerate the generator being fixed to the tendon, even though the technique is identical for everyone. The fix is a second procedure at three months to disconnect it from the tendon and anchor it instead to the capsule the body has formed around it.
Lead problems. Leads can break, erode into the stomach, or become encased in enough scar tissue to demand high settings. Any of these means removal or replacement.
Needing a pyloroplasty later. For patients who go straight to the stimulator, the pylorus can become the limiting problem over time — the device becomes less effective, and a pyloroplasty restores the response.
On "rejection"
Patients ask whether the body can reject the stimulator. Technically, no — rejection is something that happens to organs and tissue from another person, not to inert objects. What the body does do is form a capsule around any foreign object to wall it off. That’s normal and expected. Per Enterra Medical, there has been a single reported case of titanium allergy across all gastric stimulators ever placed.
For comparison: published series report long-term complication rates of 7–10% for gastric electrical stimulation, most commonly infection of the generator pocket, along with lead dislodgement and, rarely, bowel obstruction from the leads. Vanguard’s own figures are above.
Individual results vary. No surgical outcome can be guaranteed.
Watch the operation
Dr. Hughes has published a recording of a laparoscopic gastric stimulator placement, edited down to about five minutes, on the Vanguard YouTube channel.
Insurance and denials
Denials used to be routine in gastroparesis care. They have become infrequent — but they still happen, and a denial is not the end of the conversation. When a placement is denied, Dr. Hughes does the peer-to-peer review himself, physician to physician with the insurer’s reviewer, explaining why this patient needs this device. If necessary, he can appeal the denial on your behalf.
“Thank you all so much for helping me get my health back and for being able to enjoy my life again. I thank God every day for your kindness and skills.”
— Katherine, pyloroplasty and gastric stimulator placement
“Thank you, Dr. Hughes, for being such an awesome champion for us GP sufferers. After struggling with GP for 20+ years, I am SO thankful to FINALLY have someone in my corner that can help. You have made a world of difference in my life. Thank you SO MUCH!”
— Jessica, pyloroplasty and gastric stimulator placement
Start with the seminar. Decide afterwards.
One hour, online, free, and it commits you to nothing. You do not need to live in Kentucky or Indiana.
Questions? Call (502) 912-8300, Monday–Friday 8:00 am – 4:00 pm ET.