Absorbable antibacterial envelope in the surgical management of Twiddler’s syndrome in a patient with gastric electric stimulator: a case report

Gastroparesis is a chronic gastric motility disorder characterized by delayed gastric emptying and a multitude of troublesome symptoms, including chronic nausea, vomiting, abdominal pain, malnutrition, and dehydration. Whereas initial management of the gastroparesis is conservative, patient with refractory gastroparesis may benefit from surgical therapy, including gastric electric stimulator (GES) device implantation. Twiddler’s syndrome is a challenging condition well described in the cardiac literature that is characterized by the instability, displacement, leads twisting and resulting malfunction of an implanted device, believed to be due to manipulation (twiddling) by the patient. The condition is not specifically characterized in the GES literature; however, evidence suggest the incidence of the Twiddler’s syndrome is reaching up to 9% of the patients with GES. In the current report we present a case of surgical management of the recurrent Twiddler’s syndrome in a patient with a GES device with novel non-FDA approved use of the TYRX(™) Absorbable Antibacterial Envelope for the device stabilization. Use of the TYRX(™) enveloped provided additional anchoring points of fixation, resulting in the successful resolution of the device instability and the Twiddler’s syndrome with and ongoing follow up of up to 8 months. This report adds to the armamentarium of surgical management of this uncommon and difficult problem.