Pyloric injection of botulinum toxin for treatment of diabetic gastroparesis

BACKGROUND: Diabetic gastroparesis is a common clinical problem. The pathophysiology includes prolonged pyloric contractions that may cause functional resistance to gastric outflow. Botulinum toxin was injected into the pyloric sphincter in an attempt to decrease pyloric resistance and improve gastric emptying. METHODS: Six patients with diabetic gastroparesis and an abnormal solid phase gastric emptying study underwent upper endoscopy during which 100 units of botulinum toxin were injected into the pyloric sphincter. Gastric emptying studies were obtained at 48 hours and 6 weeks after injection. Patients were questioned about symptoms of gastroparesis, and a symptom score was obtained at baseline and at 2 weeks and 6 weeks after injection. OBSERVATIONS: There was a mean improvement in the subjective symptom score at 2 weeks of 55% (range 14% to 80%). This improvement was maintained at 6 weeks. There was a 52% improvement in gastric emptying at 2 and 6 weeks. CONCLUSION: Pyloric injection of botulinum toxin can improve symptoms and gastric emptying in patients with diabetic gastroparesis. Further evaluation of pyloric injection of botulinum toxin as a treatment for diabetic gastroparesis is warranted.     

Effect of metoclopramide in diabetic gastroparesis

The aims of our study were to: determine the effect of metoclopramide parenterally and orally on delayed gastric emptying of a radionuclide test meal in symptomatic patients with diabetic gastroparesis not explained by ulceration or other mechanical problems; and evaluate in a double-blind crossover fashion the efficacy of metoclopramide in relieving the symptoms of diabetic gastroparesis. Thirteen patients with subjective evidence of gastric stasis had delayed gastric emptying of an isotope-labeled semisolid meal which was significantly accelerated (p less than 0.05) after 10 mg of metoclopramide parenterally. Patients then received metoclopramide 10 mg and placebo before meals and prior to retiring for 3 weeks in a randomized double-blind crossover design. During metoclopramide therapy nausea, vomiting, anorexia, fullness, and bloating were significantly (p less than 0.05) ameliorated compared to placebo with an overall mean symptom reduction of 52.6%. Gastric emptying studies after completion of the trial is seven patients, subjectively improved and receiving open-labeled metoclopramide, showed significantly less gastric retention. Individual improvements in gastric emptying after parenteral or oral metoclopramide, however, could not be correlated with symptom change during the treatment trial. We conclude that metoclopramide is an important therapeutic adjunct in the management of diabetic gastroparesis and its therapeutic effects are mediated through its prokinetic properties as well as centrally mediated antiemetic actions.     

Postprandial Plasma Glucose Response and Gastrointestinal Symptom Severity in Patients With Diabetic Gastroparesis

Background:Gastroparesis is a well-known diabetic complication. The pathogenesis is not fully understood. However, it is important to early diagnose these patients.Method:This study evaluated the plasma glucose response after a test meal, and gastrointestinal (GI) symptom severity in patients with clinical suspicion of diabetic gastroparesis, and assessed its usefulness to predict gastroparesis. In all, 83 subjects with insulin-treated diabetes mellitus (DM) type 1 and 2 were included; 53 subjects had gastroparesis and 30 had normal gastric emptying determined by gastric scintigraphy. GI symptom severity during the preceding 2 weeks was evaluated with a validated questionnaire. The test meal consisted of 100 g meat, 40 g pasta, 150 g carrot, and 5 g oil. The subjects ingested the meal under fasting conditions, and plasma glucose was followed during 180 minutes.Results:Patients with gastroparesis demonstrated a blunted plasma glucose response after a test meal versus patients with normal gastric emptying (P < .005), reflected by lower maximum increase in plasma glucose response and incremental area under the curve of the plasma glucose, but a similar time to the maximum plasma glucose level. All GI symptoms were more severe in patients with gastroparesis. GI symptom severity had the best discriminative value to identify patients with gastroparesis with an area under the receiver operating curve of 0.83 (optimal cutoff: sensitivity 87%, specificity 80%).Conclusions:Patients with diabetic gastroparesis have a blunted postprandial plasma glucose response. Combining this information with the presence of GI symptoms can help clinicians identify diabetic patients with gastroparesis.     

Gastric emptying of solid and liquid meals in healthy controls compared with long-term type-1 diabetes mellitus under optimal glucose control.

BACKGROUND: Neuropathy of the enteric nervous system and hyperglycaemia are regarded as the main causes of diabetic gastroparesis. PATIENTS AND METHODS: In ten patients with Type-1 diabetes mellitus and sensomotoric neuropathy gastric emptying half times were compared with ten healthy controls by employing the 13C-octanoic acid and the 13C-sodiumacetate breath test, resp., following the intake of equally composed and isocaloric liquid and solid meals. Plasma glucose concentrations were controlled by permanent intravenous administration of insulin. RESULTS: In diabetes mellitus gastric emptying half times after the intake of the liquid meal (p < 0.05) but not after ingestion of the solid meal were slightly prolonged. Gastric emptying half times in patients and controls were not different when liquid and solid meals were compared. CONCLUSIONS: Acute hyperglycaemia appears to be more important than the neuropathy of the enteric nervous system in the pathophysiology of diabetic gastroparesis. The rate of gastric emptying is obviously not dependent on the phase of a meal, but rather on the composition and the caloric content.     

Disordered gastric motor function in diabetes mellitus

Summary The application of novel investigative techniques has demonstrated that disordered gastric motility occurs frequently in diabetes mellitus. Gastric emptying is abnormal in about 50% of diabetic patients and delay in gastric emptying of nutrient-containing meals is more common than rapid emptying. The blood glucose concentration influences gastric motility in diabetes. In IDDM patients, gastric emptying is retarded during hyperglycaemia and may be accelerated by hypoglycaemia. Gastroparesis therefore does not necessarily reflect irreversible autonomic neuropathy and blood glucose concentrations must be monitored when gastric motility is evaluated in diabetic patients. There is a poor relationship between gastric emptying and gastrointestinal symptoms and the mechanisms by which abnormal motility causes symptoms are unclear. The introduction of new gastrokinetic drugs has improved therapeutic options for the management of symptomatic patients with gastroparesis considerably. The contribution of disordered gastric emptying to poor glycaemic control is unclear, but the demonstration that the rate of gastric emptying is a major factor in normal blood glucose homeostasis suggests that this is likely to be significant.Abbreviations IDDM insulin-dependent diabetes mellitus - NIDDM non-insulin-dependent diabetes mellitus     

Nutrition therapy for diabetic gastroparesis

The management of diabetic gastroparesis often represents a significant clinical challenge in which the maintenance of nutrition is pivotal. Gastric emptying is delayed in 30% to 50% of patients with longstanding type 1 or type 2 diabetes and upper gastrointestinal symptoms also occur frequently. However, there is only a weak association between the presence of symptoms and delayed gastric emptying. Acute changes in blood glucose concentrations affect gastric motility in diabetes; hyperglycemia slows gastric emptying whereas hypoglycemia may accelerate it; blood glucose concentrations may also influence symptoms. It is now recognized that gastric emptying is a major determinant of postprandial glycemia and, therefore, there is considerable interest in the concept of modulating gastric emptying, by dietary or pharmacologic means, to optimize glycemic control in diabetes.     

Delayed gastric emptying: Whom to test, how to test, and what to do

Opinion statement Gastroparesis, or delayed gastric emptying, is a common cause of chronic nausea and vomiting as seen in a gastroenterology practice. Diabetic, postsurgical, and idiopathic causes remain the three most common forms of gastroparesis. In addition to nausea and vomiting, symptoms of gastroparesis may include early satiety, postprandial fullness, and abdominal pain. Physiologic changes that may explain symptoms in patients with gastroparesis, in addition to delayed gastric emptying, include impaired fundic accommodation, antral hypomotility, gastric dysrhythmias, pylorospasm, and perhaps visceral hypersensitivity. Diagnosis of gastroparesis is best determined using a radioisotope-labeled solid meal with scintigraphic imaging for at least 2 hours, and preferably 4 hours, postprandially. Most commonly, a 99mTc sulfur colloid-labeled egg sandwich with imaging at 0, 1, 2, and 4 hours is used. Extension of the gastric emptying test to 4 hours improves the accuracy of the test, but unfortunately, this is not commonly performed at many centers. Emptying of liquids remains normal until the late stages of gastroparesis and is less useful. The aims of treatment should be to control symptoms and maintain adequate nutrition and hydration. Patients should be advised to eat small meals and to limit their intake of fat and fiber. Additional dietary recommendations may include increasing caloric intake in the form of liquids. For diabetic patients, control of blood glucose levels is important, as symptom exacerbation is frequently associated with poor glycemic control. Specific treatment often begins with metoclopramide, 10 mg, up to four times daily, after a discussion of possible side effects with the patient. An antiemetic agent, such as prochlorperazine, 5 to 10 mg orally or 25 mg by suppository, can be added on an as-needed basis every 4 to 6 hours to control nausea. If these antiemetic medications are not effective, or if side effects develop, orally dissolving ondansetron, 8 mg every 8 to 12 hours, can be tried on an as-needed basis. If this regimen is unsuccessful, then alternative prokinetic agents—erythromycin, 125 mg, or tegaserod, 6 mg, prior to meals—can be tried. For cases refractory to these treatments, referral to a center with US Food and Drug Administration permission to use domperidone should be considered. Alternatively, symptom modulators such as low-dose tricyclic antidepressants can be tried to reduce symptoms, but these do not improve gastric emptying. In patients for whom all medical therapy fails, other options that are tried at experienced centers include the injection of botulinum toxin into the pylorus, placement of a feeding jejunostomy, and/or placement of a gastric electrical stimulator.     

Novel insights into the effects of diabetes on gastric motility

Recent data from the Diabetes Control and Complications Trial/Epidemiology of Diabetic Interventions and Complications cohort indicate that the disease burden of gastroparesis in diabetes remains high, consistent with the outcome of cross-sectional studies in type 1 and 2 diabetes. An improved understanding of the pathogenesis of diabetic gastroparesis at the cellular level has emerged in the last decade, particularly as a result of initiatives such as the National Institute of Health funded Gastroparesis Clinical Research Consortium in the US. Management of diabetic gastroparesis involves dietary and psychological support, attention to glycaemic control, and the use of prokinetic agents. Given that the relationship between upper gastrointestinal symptoms and the rate of gastric emptying is weak, therapies targeted specifically at symptoms, such as nausea or pain, are important. The relationship between gastric emptying and postprandial glycaemia is complex and inter-dependent. Short-acting glucagon-like peptide-1 agonists, that slow gastric emptying, can be used to reduce postprandial glycaemic excursions and, in combination with basal insulin, result in substantial reductions in glycated haemoglobin in type 2 patients.     

Small particle size of a solid meal increases gastric emptying and late postprandial glycaemic response in diabetic subjects with gastroparesis

Our goal was to investigate if food of small particle size increases the gastric emptying rate and lessens the fall in postprandial blood glucose in seven subjects with Type 1 diabetes and gastroparesis. Two solid meals of identical composition but of different particle size, with 5MBq (99m)Tc added to the meals, were ingested in randomized order in seven subjects with Type 1 Diabetes Mellitus and gastroparesis and seven healthy subjects. During 180min blood glucose and insulin concentrations were measured and gastric emptying of the ingested meals was registered by a gamma camera. The lag phase in the stomach was significantly shorter, the radioactivity remaining in the stomach after 120min (T(120)) was significant less and the postprandial blood glucose dip was less and of shorter duration after a small particle (SP) meal, compared to a large particle (LP) meal in diabetic subjects. Gastric emptying did not differ significantly between groups after an SP meal. Food of small particle size increases the gastric emptying rate and reduces the postprandial blood glucose dip in both magnitude and duration in Type 1 diabetic subjects with gastroparesis, which is likely to be of importance in achieving good metabolic control.     

Diabetes mellitus and gastric emptying: questions and issues in clinical practice

It is long known that both type 1 and type 2 diabetes can be associated with changes in gastric emptying; a number of publications have linked diabetes to delayed gastric emptying of variable severity and often with poor relationship to gastrointestinal symptomatology. In contrast, more recent studies have reported accelerated gastric emptying when adjusted for glucose concentration in patients with diabetes, indicating a reciprocal relationship between gastric emptying and ambient glucose concentrations. This review proposes that gastroparesis or gastroparesis diabeticorum, a severe condition characterized by a significant impairment of gastric emptying accompanied by severe nausea, vomiting, and malnutrition, is often overdiagnosed and not well contrasted with delays in gastric emptying. The article offers a clinically relevant definition of gastroparesis that should help differentiate this rare condition from (often asymptomatic) delays in gastric emptying. The fact that delayed gastric emptying can also be observed in non‐diabetic individuals under experimental conditions in which hyperglycaemia is artificially induced suggests that a delay in gastric emptying rate when blood glucose concentrations are high is actually an appropriate physiological response to hyperglycaemia, slowing further increases in blood glucose. The article discusses the strengths and weaknesses of various methodologies for assessing gastric emptying, especially with respect to the diabetes population, and reviews newer diabetes therapies that decelerate the rate of gastric emptying. These therapies may be a beneficial tool in managing postprandial hyperglycaemia because they attenuate rapid surges in glucose concentrations by slowing the delivery of meal‐derived glucose. Copyright © 2009 John Wiley & Sons, Ltd.     

Effects of postprandial walking on delayed gastric emptying and intragastric meal distribution in longstanding diabetics

OBJECTIVE: We investigated the influence of standardized postprandial walking on the rates of gastric emptying and of intragastric meal distribution in 50 consecutive patients with longstanding insulin-dependent diabetes mellitus. METHODS: Gastric emptying of a semisolid meal labeled with 99mTc was continuously recorded with a dual-head gamma camera with patients in the supine position for 90 min before and 20 min after a 30-min postprandial walk. Regions of interest enclosing total stomach, and proximal and distal gastric compartments were calculated to determine gastric emptying rates and intragastric meal distribution. RESULTS: The evaluation of gastric emptying rates before and after postprandial walking demonstrated two variants of delayed gastric emptying: one variant that was counteracted by postprandial walking in seven patients (14%, Group I) and another variant that was not influenced by postprandial walking in 11 patients (22%, Group II). In addition, the emptying rates of 28 patients (56%) were within the range of controls and in four patients the emptying was accelerated (8%). The filling of the proximal gastric compartment was predominant and remained dominant after walking in Groups I and II. In controls and in diabetics with normal gastric emptying, the preliminary predominant filling of the proximal compartment was equalized after walking and the proximal compartment regained predominance thereafter. The changes in gastric emptying characteristics from delayed to accelerated gastric emptying may be related to the duration of diabetes (r = -0.47, p<0.03) and were not indicated by symptoms of upper GI discomfort or by secondary diabetic manifestations. CONCLUSION: Postprandial walking may improve gastric emptying in 14% of patients with longstanding insulin-dependent diabetes mellitus.     

Effect of cisapride on gastric emptying of indigestible solids in patients with gastroparesis diabeticorum. A comparison with metoclopramide and placebo

Cisapride is a prokinetic agent believed to facilitate acetylcholine release from the myenteric plexus of the gut. The effect of cisapride on gastric emptying of solids was studied in 9 diabetic patients, all of whom had delayed gastric emptying of indigestible solids (gastroparesis). Six patients had chronic nausea and vomiting, and 3 had no symptoms. Cisapride (5 mg) was given intravenously 15 min before ingestion of a 400-kcal test meal and 10 indigestible solid radiopaque markers. On separate days and in random order each patient also received intravenous metoclopramide (10 mg) or placebo 15 min before ingestion of the meal and markers. Mean gastric emptying of radiopaque markers, assessed by serial radiographs of the gastric region, was accelerated by metoclopramide and cisapride, but the difference reached significance only with cisapride (p less than 0.05). There was considerable intersubject variability in gastric emptying responses to cisapride and metoclopramide. No side effects occurred with either drug. This study indicates that acute, intravenous administration of cisapride accelerates gastric emptying of indigestible solids in patients with diabetic gastroparesis.     

Gastric emptying response to variable oral erythromycin dosing in diabetic gastroparesis

Intravenous erythromycin has been shown to improve gastric emptying in diabetic gastroparesis. Oral erythromycin also accelerates gastric emptying, but to a lesser degree. To determine if this is a dose-dependent phenomenon, gastric emptying was measured in 10 insulin-requiring diabetic patients with gastroparesis after administration of either 250 mg or 1000 mg of erythromycin or placebo. The drugs were orally administered in a randomized, double-blind fashion 30 min prior to ingestion of a meal containing [^99mTc]-sulfur colloid-labeled beef stew and [¹¹¹In]DTPA-labeled orange juice. Anterior and posterior gastric images were recorded for 3 hr at 15-min intervals using an externally positioned gamma camera. The results demonstrated that both doses of oral erythromycin significantly improved solid-phase gastric emptying. The mean half-emptying time of solids was decreased from 151±40 min with placebo to 58±10 min and 40±9 min with 250 mg and 1000 mg of erythromycin, respectively. However, a dose-dependent relationship was not demonstrated with the two doses of erythromycin employed. These results suggest that for most patients with diabetic gastroparesis, a single 250-mg dose of erythromycin will significantly improve gastric emptying. It is possible that a dose-dependent relationship will be demonstrated with doses of erythromycin less than 250 mg.     

The Treatment of Idiopathic and Diabetic Gastroparesis with Acute Intravenous and Chronic Oral Erythromycin

The objective of this study was to investigate the effects of intravenous erythromycin and chronic oral dosing of erythromycin on gastric emptying in patients with idiopathic or diabetic gastroparesis. Symptoms were assessed on oral dosing and during long-term follow-up in an ambulatory setting at a University referral center. Fourteen patients (10 idiopathic and four diabetic gastroparesis) were studied. Four patients left during the 4-wk study; two due to rash, one with cramps and vomiting on erythromycin, and one due to other medical problems. Ten patients completed the 4-wk study and commenced long-term therapy. Five of these patients experienced enough symptomatic relief to continue oral erythromycin long-term, being followed for an average period of 8.4 months. After initial documentation of delayed gastric emptying, patients received 6 mg/kg intravenous erythromycin lactobionate before a second gastric emptying study. Erythromycin base was then given orally at a dose of 500 mg tid-ac and qhs, with a final gastric emptying study performed after 4 wk. During long-term follow-up, erythromycin dosage was adjusted to minimize symptoms. Radionuclide-labeled gastric emptying of a solid meal was studied at baseline, following intravenous erythromycin, and after 4 wk of oral treatment with erythromycin. Symptom scores were assessed at baseline, at 4 wk, and then at 8-wk intervals. The percentage of the solid meal retained in the stomach at 2 h decreased from 85%±11% (SD) at baseline to 20%± 29% following intravenous erythromycin ( p < 0.001), and to 48%± 21% after 4 wk of oral therapy ( p < 0.01 vs. baseline). There was a reduction in total symptom scores and a significant reduction in global assessment scores ( p = 0.03). We conclude that erythromycin bas a strong gastric prokinetic effect in both idiopathic and diabetic gastroparesis, and may represent a useful new therapeutic approach to this problem.     

Gastric Emptying in Patients with Insulin-Requiring Diabetes Mellitus

Gastric emptying of technetium labeled liquid and solid meals were studied in a group of long-standing, insulin-requiring male diabetics to evaluate the relationship of gastroparesis to symptoms, diabetic control, and diabetic complications. Control subjects and three groups of diabetics were studied: A) no neuropathy; B) peripheral neuropathy; and C) peripheral and autonomic neuropathy. Nine diabetics had gastrointestinal symptoms. Gastric t1/2 liquid emptying was similar in all groups and in controls, but liquid gastric emptying in the first 15 min was significantly more rapid in the diabetics than controls. Solid emptying was prolonged in group C patients. There was a significant correlation between t1/2 solid emptying and the severity of neuropathy. The eight patients with slow solid emptying had more neuropathy and gastrointestinal symptoms than the remaining 22 patients. The type and duration of diabetes, diabetic control, and frequency of retinopathy are independent of gastroparesis. These data indicate that delayed emptying of solids is common (27%) in patients with clinically detectable neuropathy and may often be asymptomatic. Visceral autonomic neuropathy seems the most important underlying factor in diabetic gastroparesis.     

Gastroparesis in type 2 diabetes mellitus: Prevalence,etiology, diagnosis,and treatment

The worldwide epidemic of type 2 diabetes mellitus (T2DM) is a substantial economic and social burden. Although gastroparesis associated with type 1 diabetes mellitus (T1DM) has been recognized for years, only recently have studies shown that patients with T2DM also have high rates of gastroparesis. Individuals with T2DM constitute 90% to 95% of the diabetic population. Unique characteristics that distinguish this population are obesity, insulin resistance, and associated comorbidities. These features highlight the importance of investigating gastric emptying in individuals with T2DM and upper gastrointestinal symptoms. The purpose of this review is to examine the literature pertaining to diabetes and the effect of diabetes on gastric neuromuscular function, with a focus on T2DM. An understanding of gastric motility in T2DM is important to diagnose gastroparesis, to treat upper gastrointestinal symptoms, and to restore normal gastric motility, which may lead, in turn, to improved glucose control.     

Type 1 diabetes and gastroparesis: Diagnosis and treatment

Patients with gastroparesis present with gastrointestinal symptoms and non-gastrointestinal manifestations in association with objective delays in gastric emptying. The condition complicates the course of many patients with type 1 diabetes mellitus, usually in those with longstanding poor glycemic control with other associated diabetic complications. The diagnosis is made by directed evaluation to exclude organic diseases that can mimic the clinical presentation of gastroparesis, coupled with verification of gastric retention. Current therapy relies on dietary modifications, medications to stimulate gastric evacuation, and agents to reduce vomiting. Endoscopic and surgical options are increasingly used in patients who are refractory to drug treatment.     

2型糖尿病合并胃轻瘫患者的动态血糖谱

目的 探讨2型糖尿病合并胃轻瘫患者的动态血糖特征.方法 对31例2型糖尿病患者以核素扫描评估胃排空,并以7例正常糖调节者作对照;所有入组对象在平衡饮食状态下用动态血糖监测系统(CGMS)进行72 h血糖监测.结果 31例2型糖尿病患者中胃轻瘫占58.1%.胃轻瘫组和非胃轻瘫组在早餐后2 h平均血糖值[(7.82 4-1.42)mmol/L比(9.35 4±2.28)mmol/L]、早餐后血糖最高值[(10.21±2.17)mmol/L比(12.24±2.82 mmol/L)]和2 h平均血糖曲线下面积[(877.62±272.78)min·mmol·L-1比(1028.40±283.98)min·mmol·L-1],差异具有统计学意义(P<0.05).结论 2型糖尿病胃轻瘫患者胃排空延迟可能有助于降低餐后平均血糖.     

Gastric emptying in patients with Type 2 diabetes mellitus and diabetes associated with mitochondrial DNA 3243 mutation using 13C-octanoic acid breath test

Although the (13)C-octanoic acid breath test (OBT) has been applied to diabetic patients for assessing gastric emptying, such studies are still limited. Gastric emptying was measured using solid meal containing (13)C-octanoic acid in 52 patients with Type 2 diabetes mellitus and 4 diabetic patients with mitochondrial DNA (mitDNA) 3243 mutation. Delayed gastric emptying was detected in 29% of patients with Type 2 diabetes mellitus, and multiple regression analysis showed that gastric emptying was independently associated with gastrointestinal symptoms and cardiac autonomic neuropathy. Gastric emptying was not related to gastric dysrhythmia in cutaneous electrogastrography (EGG). Diabetic patients with mitDNA 3243 mutation showed delayed gastric emptying. Because the pathogenesis of delayed gastric emptying is multifactorial in diabetic patients, the recently developed OBT is useful for studying gastric emptying in various clinical settings of diabetic patients.     

Human gastric myoelectric activity and gastric emptying following gastric surgery and with pacing.

Postoperative gastric myoelectric activity, gastric emptying, and clinical course were correlated in 17 patients at high risk of developing gastroparesis after gastric surgery. In addition, an attempt was made to pace the stomach with an electrical stimulus and determine the effect of pacing on early postoperative gastric emptying. Gastric dysrhythmias (bradygastria, slow wave frequency < 2 cycles/min; tachygastria, slow wave frequency > 4 cycles/min) persisted beyond the first postoperative day in 6 patients (35%). Delayed gastric emptying was identified by a radionuclide meal in 15 patients (88%), but symptoms of gastroparesis developed in only 6 of 15 (40%). Patients with postoperative gastroparesis had more frequent dysrhythmias than asymptomatic patients (67% vs. 18%), but these differences were not significant, although we cannot exclude a type II statistical error. Gastric rhythm was entrained in 10 of 16 patients (63%). Pacing increased the gastric slow wave frequency (3.1 vs. 4.1 cycles/min; P < 0.01) but did not improve gastric emptying (gastric retention at 60 minutes, 86% +/- 6% for control and 90% +/- 2% for paced). In conclusion, gastric dysrhythmias do not appear to play a major role in the development of postsurgical gastroparesis. Although gastric rhythm could be entrained in the majority of patients, pacing did not improve gastric emptying overall.