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El Abiad R, Ashat M, Khashab M. Complications related to third space endoscopic procedures. Best Pract Res Clin Gastroenterol 2024; 71:101908. [PMID: 39209411 DOI: 10.1016/j.bpg.2024.101908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 02/06/2024] [Accepted: 03/19/2024] [Indexed: 09/04/2024]
Abstract
Third space endoscopy (TSE) encompasses a breadth of procedures for the treatment of a variety of GI disorders. The widespread use of per-oral endoscopic myotomy (POEM) and its diversification to include extended indications and at locations other than the oesophagus has provided an insight into the potential complications encountered. The most common adverse events associated with POEM, the epitome of TSE procedures, include insufflation related injuries, bleeding, failure of mucosal barrier, infections, pain, blown out myotomy and gastroesophageal reflux disease. The purpose of this review is to highlight the pitfalls and to identify the risk factors that may lead to adverse events, and to recommend appropriate salvage interventions in the scope of the current evidence.
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Affiliation(s)
- Rami El Abiad
- Division of Gastroenterology and Hepatology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA.
| | - Munish Ashat
- Division of Gastroenterology and Hepatology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Mouen Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, MD, USA
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2
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Vasatko M, Evinova E, Hugova K, Simkova D, Yepishkina K, Amin S, Martinek J. Endoscopic pyloromyotomy for treatment of gastroparesis: A new standard or still an experimental approach? Best Pract Res Clin Gastroenterol 2024; 71:101910. [PMID: 39209413 DOI: 10.1016/j.bpg.2024.101910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Accepted: 04/03/2024] [Indexed: 09/04/2024]
Abstract
Gastroparesis (GP) can be a severe and debilitating disease. Its pathophysiology is complex and not completely understood. Two principal mechanisms are responsible for the development of symptoms - gastric hypomotility and pylorospasm. Pylorus targeted therapies aim to decrease presumably elevated pyloric tone - pylorospasm. There is a growing body of evidence about their role in the treatment algorithm of GP. G-POEM (endoscopic pyloromyotomy) is an extensively studied pylorus targeted therapy. Its efficacy ranges between 56 and 80% and the number of recurrences among those with treatment effect seems low. G-POEM is a safe procedure with very low frequency of severe adverse events. At present, G-POEM should not be considered as an experimental approach and may be offered to all patients with refractory and severe GP. Nevertheless, G-POEM is not a first line treatment. Conservative measures such as diet modification and pharmacotherapy should always be tried before G-POEM is considered. Further research must focus on better patient selection as at present there are no standardized criteria. Functional imaging such as impedance planimetry (EndoFlip) may hold promise in this regard.
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Affiliation(s)
- Martin Vasatko
- Department of Hepatogastroenterology, Institute of Clinical and Experimental Medicine, Prague, Czech Republic; Institute of Physiology, Charles University in Prague, Prague, Czech Republic
| | - Eva Evinova
- Institute of Physiology, Charles University in Prague, Prague, Czech Republic; Department of Gastroenterology, Vitkovice Hospital, Czech Republic
| | - Kristina Hugova
- Department of Hepatogastroenterology, Institute of Clinical and Experimental Medicine, Prague, Czech Republic; Institute of Physiology, Charles University in Prague, Prague, Czech Republic
| | - Dagmar Simkova
- Department of Hepatogastroenterology, Institute of Clinical and Experimental Medicine, Prague, Czech Republic; Institute of Physiology, Charles University in Prague, Prague, Czech Republic
| | - Katerina Yepishkina
- Department of Hepatogastroenterology, Institute of Clinical and Experimental Medicine, Prague, Czech Republic
| | - Sunil Amin
- Division of Digestive Health and Liver Disease, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Jan Martinek
- Department of Hepatogastroenterology, Institute of Clinical and Experimental Medicine, Prague, Czech Republic; Institute of Physiology, Charles University in Prague, Prague, Czech Republic; Faculty of Medicine, Ostrava University, Ostrava, Czech Republic.
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3
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Yang DY, Camilleri M. The goals for successful development of treatment in gastroparesis. Neurogastroenterol Motil 2024:e14849. [PMID: 38884392 DOI: 10.1111/nmo.14849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 04/10/2024] [Accepted: 06/05/2024] [Indexed: 06/18/2024]
Abstract
BACKGROUND Gastroparesis is a motility disorder of the stomach characterized by cardinal symptoms and delayed gastric emptying of solid food in the absence of mechanical obstruction. There is significant unmet need in its management, and essentially there are no medications approved for its treatment over four decades. PURPOSE The objectives of this review are to develop an understanding of the goals of treatment, the evidence-based criteria for treatment success based on the current scientific understanding of gastroparesis as well as patient response outcomes, and to propose evidence-based principles for the successful development of treatments for gastroparesis. Specifically, we discuss the pathophysiologic targets in gastroparesis, eligibility criteria for clinical trial participation based on validated gastric emptying studies, and the patient response outcome measures that have been validated to appraise effects of treatment on clinically relevant outcomes. These considerations lead to recommendations regarding eligibility, design, and duration of proof-of-efficacy studies, and to endorsing the American Neurogastroenterology and Motility Society Gastroparesis Cardinal Symptom Index Daily Diary as a validated patient response outcome and to justification of the shortening of proof-of-efficacy, placebo-controlled clinical trials to 4 weeks treatment duration after a baseline period. We believe that such approaches will increase the likelihood of successful assessment of efficacy of novel approaches to treating patients with gastroparesis.
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Affiliation(s)
- David Yi Yang
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Dolan RD, McCarty TR, Bazarbashi AN, Thompson CC. Efficacy and Safety of Gastric Per-Oral Endoscopic Myotomy (G-POEM): A Systematic Review and Meta-Analysis. J Clin Gastroenterol 2024:00004836-990000000-00293. [PMID: 38683239 DOI: 10.1097/mcg.0000000000002010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 03/17/2024] [Indexed: 05/01/2024]
Abstract
BACKGROUND Gastric per-oral endoscopic myotomy (G-POEM) is an innovative treatment that has become increasingly utilized for patients with refractory gastroparesis. The aim of this systematic review and meta-analysis was to evaluate the safety and effectiveness of G-POEM for the treatment of gastroparesis. METHODS Individualized search strategies were developed through February 2021 in accordance with the PRISMA and MOOSE guidelines. This meta-analysis was performed by calculating pooled proportions and mean difference preprocedure and postprocedure with rates estimated using random effects models. Measured outcomes included technical success, clinical success, improvement in gastroparesis cardinal symptom index (GCSI), change in gastric emptying rate, alterations in impedance planimetry (functional lumen imaging probe [FLIP]) assessment, and adverse events. RESULTS A total of 20 studies (n=797 patients; 67.41% female) were included. The mean age was 48.92±11.61 y, with an average duration of 4.24±1.11 y since gastroparesis diagnosis. Technical success was 98.47% [(95% CI: 97.14, 99.19);I2=0.00] with a mean myotomy length of 3.78±1.16 cm. In terms of clinical success, mean preprocedure GCSI scores were 3.38±0.37 and improved significantly postprocedure [weighted mean difference -1.56 (95% CI: -1.89 to -1.24); I2=82.53; P<0.001]. Gastric retention after 4 hours demonstrated ~50% improvement (preprocedure 43.08±9.24% versus postprocedure 22.97±10.19%; P<0.001). FLIP assessment with 40 mL and 50 mL balloons demonstrated a significant increase in diameter, distensibility index, and cross-sectional area postprocedure (all P<0.05). Procedure-associated adverse events occurred among 10.92% [(95% CI 5.09 to 19.32); I2=82.85] of patients. CONCLUSION G-POEM appears safe and highly effective for the treatment of patients with refractory gastroparesis regardless of symptom predominance or etiology.
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Affiliation(s)
- Russell D Dolan
- Division of Gastroenterology, Hepatology and Endoscopy. Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Thomas R McCarty
- Houston Methodist Hospital, Lynda K. and David M. Underwood Center for Digestive Disorders, Houston, TXWeill Cornell Medical College, New York, NYTexas A&M University School of Medicine, Bryan College Station, TX
| | - Ahmad Najdat Bazarbashi
- Division of Gastroenterology, Washington University in St. Louis School of Medicine. St. Louis, MO
| | - Christopher C Thompson
- Division of Gastroenterology, Hepatology and Endoscopy. Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Chang SY, Jin GH, Sun HB, Yang D, Tang TY. Applications of gastric peroral endoscopic myotomy in the treatment of upper gastrointestinal tract disease. World J Gastrointest Surg 2024; 16:658-669. [PMID: 38577089 PMCID: PMC10989344 DOI: 10.4240/wjgs.v16.i3.658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 01/15/2024] [Accepted: 02/08/2024] [Indexed: 03/22/2024] Open
Abstract
Gastric peroral endoscopic myotomy (G-POME) is an emerging minimally invasive endoscopic technique involving the establishment of a submucosal tunnel around the pyloric sphincter. In 2013, Khashab et al used G-POME for the first time in the treatment of gastroparesis with enhanced therapeutic efficacy, providing a new direction for the treatment of gastroparesis. With the recent and rapid development of G-POME therapy technology, progress has been made in the treatment of gastroparesis and other upper digestive tract diseases, such as congenital hypertrophic pyloric stenosis and gastric sleeve stricture, with G-POME. This article reviews the research progress and future prospects of G-POME for the treatment of upper digestive tract gastrointestinal diseases.
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Affiliation(s)
- Shi-Yu Chang
- Department of Gastroenterology, The First Hospital of Jilin University, Changchun 130021, Jilin Province, China
| | - Guo-Hua Jin
- Department of Gastroenterology, The First Hospital of Jilin University, Changchun 130021, Jilin Province, China
| | - Hai-Bo Sun
- Department of Gastroenterology, The First Hospital of Jilin University, Changchun 130021, Jilin Province, China
| | - Dong Yang
- Department of Gastroenterology, The First Hospital of Jilin University, Changchun 130021, Jilin Province, China
| | - Tong-Yu Tang
- Department of Gastroenterology, The First Hospital of Jilin University, Changchun 130021, Jilin Province, China
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Patel D, Jose F, Baker J, Moshiree B. Neurogastroenterology and Motility Disorders of the Gastrointestinal Tract in Cystic Fibrosis. Curr Gastroenterol Rep 2024; 26:9-19. [PMID: 38057499 DOI: 10.1007/s11894-023-00906-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/26/2023] [Indexed: 12/08/2023]
Abstract
PURPOSE OF REVIEW To discuss all the various motility disorders impacting people with Cystic Fibrosis (PwCF) and provide diagnostic and management approaches from a group of pediatric and adult CF and motility experts and physiologists with experience in the management of this disease. RECENT FINDINGS Gastrointestinal (GI) symptoms coexist with pulmonary symptoms in PwCF regardless of age and sex. The GI manifestations include gastroesophageal reflux disease, esophageal dysmotility gastroparesis, small bowel dysmotility, small intestinal bacterial overgrowth syndrome, distal idiopathic obstruction syndrome, constipation, and pelvic floor disorders. They are quite debilitating, limiting the patients' quality of life and affecting their nutrition and ability to socialize. This genetic disorder affects many organ systems and is chronic, potentially impacting fertility and future family planning, requiring a multidisciplinary approach. Our review discusses the treatments of motility disorders in CF, their prevalence and pathophysiology. We have provided a framework for clinicians who care for these patients that can help to guide their clinical management.
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Affiliation(s)
- Dhiren Patel
- Department of Pediatrics, Pediatric Gastroenterology, Hepatology and Nutrition, SSM Cardinal Glennon Children's Medical Center, Saint Louis University, St Louis, MO, USA
| | - Folashade Jose
- Pediatric Gastroenterology, Hepatology, and Nutrition, Clinical Associate Professor, Levine Childrens Hospital, Carolina Pediatric Gastroenterology, Charlotte, NC, USA
| | | | - Baha Moshiree
- Division of Gastroenterology, Atrium Health Wake Forest Medical University, Charlotte, NC, USA.
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Kuhar S, Seo JH, Pasricha PJ, Mittal R. In silico modelling of the effect of pyloric intervention procedures on gastric flow and emptying in a stomach with gastroparesis. J R Soc Interface 2024; 21:20230567. [PMID: 38263890 PMCID: PMC10824103 DOI: 10.1098/rsif.2023.0567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 01/02/2024] [Indexed: 01/25/2024] Open
Abstract
Pyloric interventions are surgical procedures employed to increase the gastric emptying rate in gastroparesis patients. In this study, we use an in silico model to investigate the consequences of pyloric intervention on gastric flow and emptying for two phenotypes of gastroparesis: antral hypomotility and decreased gastric tone. The transpyloric pressure gradient predicted by the in silico model, based on viscous fluid flow equations, is compared against in vivo measurements. Both phenotypes exhibit a similar pre-procedural emptying rate reduction, but after pyloric surgery, antral hypomotility case with preserved gastric tone shows significant improvements in emptying rates, up to 131%, accompanied by bile reflux from the duodenum into the stomach. Conversely, severely reduced gastric tone cases exhibited a post-procedural reduction in the net emptying rate due to the relatively larger bile reflux. In cases with a combination of antral hypomotility and reduced gastric tone, post-procedural improvements were observed only when both conditions were mild. Our findings highlight the pivotal role of the relative increase in pyloric orifice diameter in determining post-operative emptying rates. The study suggests a possible explanation for the selective response of patients toward these procedures and underscores the potential of in silico modelling to generate valuable insights to inform gastric surgery.
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Affiliation(s)
- Sharun Kuhar
- Department of Mechanical Engineering, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Jung-Hee Seo
- Department of Mechanical Engineering, Johns Hopkins University, Baltimore, MD 21218, USA
| | | | - Rajat Mittal
- Department of Mechanical Engineering, Johns Hopkins University, Baltimore, MD 21218, USA
- Department of Medicine, Johns Hopkins University, Baltimore, MD 21205, USA
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Horváth ÖP, Pavlovics G, Cseke L, Vereczkei A, Papp A. Dysphagia After Esophageal Replacement and Its Treatment. Dysphagia 2023; 38:1323-1332. [PMID: 36719515 PMCID: PMC10471736 DOI: 10.1007/s00455-023-10557-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 01/10/2023] [Indexed: 02/01/2023]
Abstract
Dysphagia occurs temporarily or permanently following esophageal replacement in at least half of the cases. Swallowing disorder, in addition to severe decline in the quality of life, can lead to a deterioration of the general condition, which may lead to death if left untreated. For this reason, their early detection and treatment are a matter of importance. Between 1993 and 2012, 540 esophageal resections were performed due to malignant tumors at the Department of Surgery, Medical Center of the University of Pécs. Stomach was used for replacement in 445 cases, colon in 38 cases, and jejunum in 57 cases. The anastomosis with a stomach replacement was located to the neck in 275 cases and to the thorax in 170 cases. The colon was pulled up to the neck in each case. There were 29 cases of free jejunal replacements located to the neck and 28 cases with a Roux loop reconstruction located to the thorax. Based on the literature data and own experience, the following were found to be the causes of dysphagia in the order of frequency: anastomotic stenosis, conduit obstruction, peptic and ischemic stricture, foreign body, local recurrence, functional causes, new malignant tumor in the esophageal remnant, and malignant tumor in the organ used for replacement. Causes may overlap each other, and their treatment may be conservative or surgical. The causes of many dysphagic complications might be prevented by improving the anastomosis technique, by better preservation the blood supply of the substitute organ, by consistently applying a functional approach, and by regular follow-up.
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Affiliation(s)
- Örs Péter Horváth
- Department of Surgery, Medical Center, Pécs University, Ifjúság u. 13, 7624, Pécs, Hungary.
| | - Gábor Pavlovics
- Department of Surgery, Medical Center, Pécs University, Ifjúság u. 13, 7624, Pécs, Hungary
| | - László Cseke
- Department of Surgery, Medical Center, Pécs University, Ifjúság u. 13, 7624, Pécs, Hungary
| | - András Vereczkei
- Department of Surgery, Medical Center, Pécs University, Ifjúság u. 13, 7624, Pécs, Hungary
| | - András Papp
- Department of Surgery, Medical Center, Pécs University, Ifjúság u. 13, 7624, Pécs, Hungary
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Albéniz E, Marra-López Valenciano C, Estremera-Arévalo F, Sánchez-Yagüe A, Montori S, Rodríguez de Santiago E. POEM from A to Z: current perspectives. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2023. [PMID: 37073708 DOI: 10.17235/reed.2023.9602/2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/20/2023]
Abstract
The "third space endoscopy" or also called "submucosal endoscopy" is a reality we can transfer to our patients since 2010. Various modifications of the submucosal tunneling technique allow access to the submucosa or deeper layers of the gastrointestinal tract. In addition to peroral endoscopic myotomy for the treatment of achalasia, also called esophageal POEM, other variants have emerged that make it possible to treat different esophageal motility disorders, esophageal diverticula, subepithelial tumors of various locations, gastroparesis, reconnection of complete esophageal strictures or even thanks to exceptional endoscopists, pediatric disorders such as Hirschsprung's disease. Although some technical aspects are yet to be standardized, these procedures are becoming widespread worldwide and will likely become the standard treatment of these pathologies soon.
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Affiliation(s)
- Eduardo Albéniz
- Endoscopy Unit. Gastroenterology, Hospital Universitario de Navarra (HUN). Navarrabiomed. UPNA, IdiSNA, España
| | | | | | | | - Sheyla Montori
- Gastrointestinal Endoscopy Research Unit, Hospital Universitario de Navarra (HUN). Navarrabiomed. UPNA, IdiSNA, Spain
| | - Enrique Rodríguez de Santiago
- Gastroenterology and Hepatology , Hospital Universitario Ramón y Cajal. Universidad de Alcalá. IRYCIS. CIBERehd. ISCIII, Spain
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El Halabi M, Parkman HP. 2023 update on the clinical management of gastroparesis. Expert Rev Gastroenterol Hepatol 2023; 17:431-441. [PMID: 36970885 DOI: 10.1080/17474124.2023.2196404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
INTRODUCTION Gastroparesis is characterized by symptoms suggesting gastric retention of food and objective evidence of delayed gastric emptying in the absence of a mechanical obstruction. Nausea, vomiting, early satiety, and postprandial fullness are the classic symptoms of gastroparesis. Gastroparesis is increasingly encountered by physicians. There are several recognized etiologies of gastroparesis, including diabetic, post-surgical, medication-induced, post-viral, and idiopathic. AREAS COVERED A comprehensive literature review was conducted to identify studies discussing gastroparesis management. Dietary modifications, medication adjustments, glucose control, antiemetic agents, and prokinetic agents are all part of gastroparesis management. In this manuscript, we detail treatments evolving for gastroparesis, including nutritional, pharmaceutical, device, and recent advanced endoscopic and surgical therapies. This manuscript concludes with a speculative viewpoint on how the field will evolve in 5 years' time. EXPERT OPINION Identification of the dominant symptoms (fullness, nausea, abdominal pain, and heartburn) helps to direct management efforts of the patients. Treatments for refractory (treatment resistant) symptoms may include gastric electric stimulation and intra-pyloric interventions like botulinum toxin and endoscopic pyloromyotomy. Understanding the pathophysiology of gastroparesis, relating pathophysiologic abnormalities to specific symptoms, new efficacious pharmacotherapies, and better understanding of the clinical predictors of response of therapies, are priorities for future research in the field of gastroparesis.
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Affiliation(s)
- Maan El Halabi
- GI Motility Fellow, Section of Gastroenterology, Temple University Hospital, Philadelphia, PA, USA
| | - Henry P Parkman
- Professor of Medicine, Director of GI Motility Laboratory, Section of Gastroenterology, Temple University Hospital, Philadelphia, PA, USA
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Gastroparesis: An Evidence-Based Review for the Bariatric and Foregut Surgeon. Surg Obes Relat Dis 2023; 19:403-420. [PMID: 37080885 DOI: 10.1016/j.soard.2023.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 02/24/2023] [Indexed: 03/06/2023]
Abstract
Gastroparesis is a gastric motility disorder characterized by delayed gastric emptying. It is a rare disease and difficult to treat effectively; management is a dilemma for gastroenterologists and surgeons alike. We conducted a systematic review of the literature to evaluate current diagnostic tools as well as treatment options. We describe key elements in the pathophysiology of the disease, in addition to current evidence on treatment alternatives, including nutritional considerations, medical and surgical options, and related outcomes.
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Wadhwa V, Gonzalez A, Azar F, Singh H, Gupta K, Liang H, Schneider A, Ponsky J, Erim T, Rodriguez J, Castro FJ. Response to botulinum toxin may predict response to peroral pyloromyotomy in patients with gastroparesis. Endoscopy 2023; 55:508-514. [PMID: 36417930 DOI: 10.1055/a-1986-4292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND : Patients with gastroparesis who have undergone prior intrapyloric botulinum toxin injection (BTI) may seek an opinion regarding peroral pyloromyotomy (POP). There are only two small reports assessing the role of BTI as a predictor for successful treatment with POP. METHODS We performed a retrospective cohort study to assess whether symptomatic improvement after BTI predicts a response to POP. We included 119 patients who had undergone both BTI and POP at Cleveland Clinic Ohio or Cleveland Clinic Florida from January 2016 to September 2019. RESULTS 65.5 % of patients had symptomatic improvement after BTI. Gastroparesis Cardinal Symptom Index (GCSI) scores were available for 74 patients, with 64 % achieving a response to POP, defined as a decrease in mean GCSI ≥ 1. In multivariable analysis, response to BTI (odds ratio [OR] 7.7 [95 %CI 2.2-26.1]) and higher pre-POP GCSI score (OR 2.3 [95 %CI 1.2-4.6]) were independent predictors of response to POP. CONCLUSIONS Clinical improvement after BTI is a predictor of response to POP in patients with gastroparesis. This information may aid in improving patient selection for POP.
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Affiliation(s)
- Vaibhav Wadhwa
- Center for Interventional Gastroenterology, University of Texas Health Science, Houston, Texas, United States
| | - Adalberto Gonzalez
- Department of Gastroenterology and Hepatology, Cleveland Clinic Florida, Weston, Florida, United States
| | - Francisco Azar
- Department of Gastroenterology and Hepatology, Cleveland Clinic Florida, Weston, Florida, United States
| | - Harjinder Singh
- Department of Gastroenterology and Hepatology, Cleveland Clinic Florida, Weston, Florida, United States
| | - Kapil Gupta
- Department of Gastroenterology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, United States
| | - Hong Liang
- Department of Clinical Research, Cleveland Clinic Florida, Weston, Florida, United States
| | - Alison Schneider
- Department of Gastroenterology and Hepatology, Cleveland Clinic Florida, Weston, Florida, United States
| | - Jeffery Ponsky
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, United States
| | - Tolga Erim
- Department of Gastroenterology and Hepatology, Cleveland Clinic Florida, Weston, Florida, United States
| | - John Rodriguez
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, United States
| | - Fernando J Castro
- Department of Gastroenterology and Hepatology, Cleveland Clinic Florida, Weston, Florida, United States
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Eriksson SE, Zheng P, Morton S, Maurer N, Hoppo T, Jobe BA, Ayazi S. Predictors of favorable outcome after pyloroplasty for gastroparesis: should response to pyloric dilation or Botox injection be used as a marker of surgical outcome? Surg Endosc 2023:10.1007/s00464-023-09882-2. [PMID: 36749378 DOI: 10.1007/s00464-023-09882-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 01/08/2023] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Pyloroplasty and gastric peroral endoscopic myotomy (G-POEM) are effective surgeries for gastroparesis. The primary aim of this study was to evaluate outcomes of pyloroplasty and G-POEM in patients with gastroparesis and determine factors associated with favorable outcome. The secondary aim was to assess the utility of clinical response to preoperative pyloric dilation or botulinum toxin injection (Botox) on surgical outcome, a factor conventionally used as a favorable marker. METHODS There were 204 patients who underwent pyloroplasty (n = 177) or G-POEM (n = 27) for gastroparesis at our institution from 2014 to 2021. Demographic and clinical parameters were analyzed to assess their impact on surgical outcome. A subgroup of patients who had pyloric dilation or Botox injection were assessed separately. Favorable outcome was defined as patient reported complete resolution of the predominant gastroparesis symptom. RESULTS Favorable outcome was achieved in 78.4% of patients (pyloroplasty: 79.7% and G-POEM: 70.4%, p = 0.274). Among 61 patients where pre- and postoperative gastric emptying studies (GES) were available, mean 4-hour retention significantly improved from 33.5 to 15.0% (p < 0.001) and 77.0% of patients achieved normalization. Favorable outcome was not significantly impacted by etiology of gastroparesis (p = 0.120), GERD (p = 0.518), or primary gastroparesis symptom (p = 0.244). Age ≥ 40 was a significant predictor of favorable surgical outcome on multivariate analysis [OR: 2.476 (1.224-5.008), p = 0.012]. Among the patients who had preoperative dilation (n = 82) or Botox injection (n = 46), response to these interventions was not a predictor of favorable surgical outcome (p = 0.192 and 0.979, respectively). However, preoperative Botox injection, regardless of response to injection, was associated with favorable surgical outcome [OR: 3.205 (CI 1.105-9.299), p = 0.032]. CONCLUSION Symptomatic improvement after pyloroplasty or G-POEM is independent of etiology of gastroparesis, GERD, and primary symptom. Response to dilation or Botox are not markers of response to surgery. However, patients who receive Botox are 3.2 times more likely to improve postoperatively.
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Affiliation(s)
- Sven E Eriksson
- Esophageal Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
| | - Ping Zheng
- Esophageal Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
| | - Scott Morton
- Esophageal Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
| | - Nicole Maurer
- Esophageal Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
| | - Toshitaka Hoppo
- Esophageal Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
| | - Blair A Jobe
- Esophageal Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA.,Department of Surgery, Drexel University, Philadephia, PA, USA
| | - Shahin Ayazi
- Esophageal Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA. .,Department of Surgery, Drexel University, Philadephia, PA, USA.
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14
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Soliman H, Gourcerol G. Targeting the pylorus in gastroparesis: From physiology to endoscopic pyloromyotomy. Neurogastroenterol Motil 2023; 35:e14529. [PMID: 36594414 PMCID: PMC10077918 DOI: 10.1111/nmo.14529] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 08/28/2022] [Accepted: 12/19/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND The pylorus plays a key role in the control of gastric content outflow. Impairment of pyloric physiology has been observed in gastroparesis, particularly when associated with diabetes mellitus or opioid intake or after antireflux surgery. New tools have been developed to identify pyloric dysfunction in routine care, including functional luminal impedance planimetry (FLIP). As such, a new therapeutic strategy targeting the pylorus, namely endoscopic pyloromyotomy (G-POEM), has received increasing attention and emerged as a promising treatment for gastroparesis. PURPOSE The present review details the involvement of the pyloric pathophysiology in gastroparesis, as well as clinical results of G-POEM according to the current literature.
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Affiliation(s)
- Heithem Soliman
- Physiology Department, INSERM UMR 1073, CIC-CRB 1404, Centre Hospitalo-Universitaire de Rouen, Rouen, France.,Département d'Hépato-Gastro-Entérologie, Hôpital Louis Mourier, AP-HP Nord, Université de Paris Cité, Colombes, France
| | - Guillaume Gourcerol
- Physiology Department, INSERM UMR 1073, CIC-CRB 1404, Centre Hospitalo-Universitaire de Rouen, Rouen, France
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15
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McCurdy GA, Gooden T, Weis F, Mubashir M, Rashid S, Raza SM, Morris J, Cai Q. Gastric peroral endoscopic pyloromyotomy (G-POEM) in patients with refractory gastroparesis: a review. Therap Adv Gastroenterol 2023; 16:17562848231151289. [PMID: 37007216 PMCID: PMC10052481 DOI: 10.1177/17562848231151289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 12/27/2022] [Indexed: 04/04/2023] Open
Abstract
Gastric peroral endoscopic pyloromyotomy (G-POEM or POP) is an endoscopic therapeutic modality for treatment of refractory gastroparesis. Since the first case reported in 2013, there are more than 200 papers published on G-POEM. In this narrative review, we summarize the short-term and long-term outcomes and review other important studies. The technical success rate is 100% and the short-term (within 1 year) success rate is about 50-80%. The procedure time is between 50 and 70 min while the average length of hospital stay was 2-3 days. The adverse event rate was around 10%. Few patients need further intervention. Three studies showed that at the 4-year follow-up, the response to G-POEM was durable, but there was a yearly recurrence rate of 13% or more. Redo G-POEM is feasible and can be of benefit for some patients. Most of the studies showed that long duration of illness is associated with poor outcomes. However, reliable predictors for successful outcomes are still unknown. Current literature indicates G-POEM is superior to gastric electric stimulator and surgical pyloroplasty. Endoflip has been used at G-POEM to predict the outcome, but the result is very preliminary. A recent sham study confirms the short-term efficacy of G-POEM. G-POEM is safe and about 50% of patients can be discharged to home on the same day. G-POEM allows for direct biopsy of the gastric muscle, which is the location of the pacemaker cells, the interstitial cells of Cajal; therefore, G-POEM may provide a new path for further research on the pathogenesis of gastroparesis.
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Affiliation(s)
- Grace Ann McCurdy
- Division of Gastroenterology and Hepatology, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Tonia Gooden
- Division of Gastroenterology and Hepatology, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Francesca Weis
- Division of Gastroenterology and Hepatology, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Maryam Mubashir
- Division of Gastroenterology and Hepatology, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Shazia Rashid
- Division of Gastroenterology and Hepatology, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Syed Musa Raza
- Division of Gastroenterology and Hepatology, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - James Morris
- Division of Gastroenterology and Hepatology, Louisiana State University Health Sciences Center, Shreveport, LA, USA
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16
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Indications and Outcomes of Per Oral Endoscopic Myotomy from Mouth to Anus. Gastrointest Endosc Clin N Am 2023; 33:99-125. [PMID: 36375890 DOI: 10.1016/j.giec.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Third space endoscopy or submucosal endoscopy using a mucosal flap valve allows secure access to the submucosal and deeper layers of the gastrointestinal tract without the risk of a full-thickness perforation. This allows the performance of submucosal tunneling and myotomy for spastic segments of the gastrointestinal tract. Per oral endoscopic myotomy (POEM) has been described for the treatment of achalasia cardia and other spastic esophageal disorders and is widely implemented. Endoscopic pyloromyotomy (G-POEM) has been performed for the treatment of refractory gastroparesis. Z-POEM for Zenker's diverticulum, D-POEM for epiphrenic diverticulum, and per-rectal endoscopic myotomy for treatment of Hirschsprung's disease are described..
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17
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Maehata T, Sato Y, Nakamoto Y, Kato M, Kawashima A, Kiyokawa H, Yasuda H, Yamamoto H, Tateishi K. Updates in the Field of Submucosal Endoscopy. LIFE (BASEL, SWITZERLAND) 2022; 13:life13010104. [PMID: 36676053 PMCID: PMC9864725 DOI: 10.3390/life13010104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 12/24/2022] [Accepted: 12/26/2022] [Indexed: 12/31/2022]
Abstract
Submucosal endoscopy (third-space endoscopy) can be defined as an endoscopic procedure performed in the submucosal space. This procedure is novel and has been utilized for delivery to the submucosal space in a variety of gastrointestinal diseases, such as a tumor, achalasia, gastroparesis, and subepithelial tumors. The main submucosal endoscopy includes peroral endoscopic myotomy, gastric peroral endoscopic myotomy, Zenker peroral endoscopic myotomy, submucosal tunneling for endoscopic resection, and endoscopic submucosal tunnel dissection. Submucosal endoscopy has been used as a viable alternative to surgical techniques because it is minimally invasive in the treatment and diagnosis of gastrointestinal diseases and disorders. However, there is limited evidence to prove this. This article reviews the current applications and evidence regarding submucosal endoscopy while exploring the possible future clinical applications in this field. As our understanding of these procedures improves, the future of submucosal endoscopy could be promising in the fields of diagnostic and therapeutic endoscopy.
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Mekaroonkamol P, Tiankanon K, Rerknimitr R. A New Paradigm Shift in Gastroparesis Management. Gut Liver 2022; 16:825-839. [PMID: 35670120 PMCID: PMC9668508 DOI: 10.5009/gnl210309] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 11/07/2021] [Accepted: 01/13/2022] [Indexed: 08/30/2023] Open
Abstract
Gastroparesis, once regarded as a rare disease, is difficult to diagnose and challenging to treat; there were many breakthrough advances in the 2010s, shifting the paradigm of the understanding of this complex entity and its management. Similar to diabetes, its increasing prevalence reflects increased accessibility to diagnostic modalities and suggests that gastroparesis was underacknowledged in the past. Major developments in the three main aspects of the disease include the discovery of smooth muscle cells, interstitial cells of Cajal, PDGFRα+ cells syncytium, rather than interstitial cells of Cajal alone, as the main gastric pacemaker unit; the development of validated point-of-care diagnostic modalities such as a wireless motility capsule, the carbon 13-labeled breath test, and impedance planimetry; and the introduction of novel minimally invasive therapeutic options such as newer pharmacologic agents and gastric peroral endoscopic pyloromyotomy. All aspects of these advances will be discussed further in this review.
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Affiliation(s)
- Parit Mekaroonkamol
- Division of Gastroenterology, Department of Medicine, King Chulalongkorn Memorial Hospital and Chulalongkorn University, Bangkok, Thailand
| | - Kasenee Tiankanon
- Division of Gastroenterology, Department of Medicine, King Chulalongkorn Memorial Hospital and Chulalongkorn University, Bangkok, Thailand
| | - Rungsun Rerknimitr
- Division of Gastroenterology, Department of Medicine, King Chulalongkorn Memorial Hospital and Chulalongkorn University, Bangkok, Thailand
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19
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Ongoing Controversies in Esophageal Cancer I. Thorac Surg Clin 2022; 32:541-551. [DOI: 10.1016/j.thorsurg.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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20
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Baret F, Jacques J, Pioche M, Albouys J, Vitton V, Vanbiervliet G, Debourdeau A, Barthet M, Gonzalez JM. Evaluation of the safety profile of endoscopic pyloromyotomy by G-POEM: a French multicenter study. Therap Adv Gastroenterol 2022; 15:17562848221122472. [PMID: 36213725 PMCID: PMC9536103 DOI: 10.1177/17562848221122472] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 08/02/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Gastric per oral endoscopic esophageal myotomy (G-POEM) is a promising procedure to treat refractory gastroparesis. The safety profile of G-POEM is an important topic because gastroparesis is a functional pathology, with a procedure whose effectiveness is between 50 and 65% depending on the studies. OBJECTIVES We present this retrospective multicenter study, with the aim of establishing a safety profile, focusing on serious adverse events (AEs). DESIGN This was a multicenter observational cohort study conducted in five French expert centers. METHODS All patients who underwent G-POEM for refractory gastroparesis between 2015 and 2021 were included for analysis. AEs were classified into per endoscopic, early postoperative, and late postoperative, up to 1 month. Their severity was assessed using Dindo-Clavien and American Society for Gastrointestinal Endoscopy classification. The primary objective was to evaluate the rate of G-POEM severe AEs. Secondary objectives were to document other postoperative AEs, and to identify predictive factors. RESULTS In all, 217 patients were included: 81 men and 136 women, mean age 52 ± 17 years. The average procedural time was 44 ± 14 min (12-78). The average hospital stay was 3.7 ± 2.3 days. The AEs rate classified as Clavien-Dindo ⩾3 was 0.4% (one delayed bleeding requiring blood transfusion and endoscopic management). There were no deaths or patients admitted to intensive care unit. The rates of mucosotomy and capnoperitoneum were 3.7 and 1.8%, respectively, without clinical consequences. Most patients (81.5%) did not experience any AE. Three cases of dumping syndrome occurred, quickly managed by dietary measures. CONCLUSION Our study confirms the safety of G-POEM with less than 0.5% of serious AEs, medically managed. This outcome makes this a procedure to have a good benefit-risk ratio.
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Affiliation(s)
| | - Jeremie Jacques
- Service de Gastroentérologie, CHU Dupuytren, Limoges, France
| | - Mathieu Pioche
- Service de Gastroentérologie, CHU Edouard Herriot, Lyon, France
| | - Jeremie Albouys
- Service de Gastroentérologie, CHU Dupuytren, Limoges, France
| | | | | | | | - Marc Barthet
- Service de Gastroentérologie, CHU Nord, Marseille, France
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21
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Abstract
Gastroparesis is characterized by symptoms suggesting retention of food in the stomach with objective evidence of delayed gastric emptying in the absence of mechanical obstruction in the gastric outflow. This condition is increasingly encountered in clinical practice. These guidelines summarize perspectives on the risk factors, diagnosis, and management of gastroparesis in adults (including dietary, pharmacological, device, and interventions directed at the pylorus), and they represent the official practice recommendations of the American College of Gastroenterology. The scientific evidence for these guidelines was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation process. When the evidence was not appropriate for Grading of Recommendations, Assessment, Development, and Evaluation, we used expert consensus to develop key concept statements. These guidelines should be considered as preferred but are not the only approaches to these conditions.
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22
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Safety and feasibility of same day discharge after per oral endoscopic pyloromyotomy in refractory gastroparesis: a pilot study. Chin Med J (Engl) 2022; 135:1432-1437. [PMID: 35866346 PMCID: PMC9481444 DOI: 10.1097/cm9.0000000000002068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Background: Gastroparesis is a debilitating medical condition with limited treatment options. Gastric per-oral pyloromyotomy (G-POEM) has emerged as a promising treatment option with remarkable short-term clinical success shown in multiple studies. While the post-procedure protocol is not standardized across many centers, the majority of the centers observes these patients in the hospital after the procedure for monitoring. In this single-center prospective study, we evaluated the safety and feasibility of same day discharge after the G-POEM procedure. Methods: All the patients with refractory gastroparesis undergoing G-POEM from October 2019 to March 2020 were enrolled. A total of 25 patients were enrolled in the procedure. Based on the pre-defined criteria, patients were either discharged on the same day after the procedure or admitted to the hospital for further observation. The patient and procedure-related data were extracted from the chart review. Univariate analysis was performed (chi-squared test) on categorical variables after organizing categorical variables as numeric counts or percentages. The student t test was performed on continuous variables after reporting as mean and standard deviation. For analysis with a smaller sample size, Fisher exact and Mann–Whitney tests were used. Results: A total of 25 patients were enrolled. The technical success of G-POEM was 100% and clinical success was 80% (20/25) at 1-month follow-up. Of the 25 patients, 9 patients (36%) were discharged on the same day according to the procedure from the recovery unit. Of the remaining 16 patients who were admitted to the hospital post-procedure, 10 (40%) were admitted due to procedure-related causes while other admissions were either pre-planned or due to social reasons. The average Charlson comorbidity index was lower in the same day discharge group (P < 0.05). The number of patients requiring double myotomy was higher in the same day discharge group (P < 0.05). The overall complication rate of G-POEM in the study cohort was 12% (3/25) with all complications being mild without any severe adverse events. Conclusion: G-POEM is a safe and effective method of treatment for refractory GP with higher clinical success in short-term follow-up. The same day discharge after G-POEM is safe and feasible in >50% of patients with close periprocedural monitoring.
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23
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Karanfilian B, Kahaleh M. New Applications for Submucosal Tunneling in Third Space Endoscopy: A Comprehensive Review. J Clin Gastroenterol 2022; 56:465-477. [PMID: 35357336 DOI: 10.1097/mcg.0000000000001694] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Third space endoscopy (TSE), a type of natural orifice transluminal endoscopic surgery, was first introduced a decade ago, and since then, has revolutionized the field of therapeutic endoscopy. TSE involves tunneling into the submucosal space between the intestinal mucosa and the muscularis propria. By accessing this "third space," endoscopists can perform minimally invasive myotomies, resections, and dissections while maintaining the mucosa and preventing full-thickness perforation. TSE procedures can be used to treat motility disorders as well as neoplasms throughout the gastrointestinal tract, which were traditionally conditions that would require open or laparoscopic surgery. The main TSE procedures include peroral endoscopic myotomy, gastric peroral endoscopic myotomy, Zenker peroral endoscopic myotomy, submucosal tunneling for endoscopic resection, endoscopic submucosal tunnel dissection, peroral endoscopic tunneling for restoration of the esophagus, and per-rectal endoscopic myotomy. Some of those procedures have now been accepted as viable alternative to surgical techniques due to their limited invasiveness, safety and cost. This review will explore the different techniques recently added to our arsenal while describing their potential efficacy and limitations.
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Affiliation(s)
- Briette Karanfilian
- Division of Gastroenterology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
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24
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Parsa N, Friedel D, Stavropoulos SN. POEM, GPOEM, and ZPOEM. Dig Dis Sci 2022; 67:1500-1520. [PMID: 35366120 DOI: 10.1007/s10620-022-07398-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/12/2022] [Indexed: 12/09/2022]
Abstract
Our tripartite narrative review discusses Peroral Endoscopic Myotomy (POEM), gastric POEM (GPOEM) and POEM for Zenker's diverticula (ZPOEM). POEM is the prototypical procedure that launched the novel "3rd space endoscopy" field of advanced endoscopy. It revolutionized achalasia therapy by offering a much less invasive version of the prior gold standard, the laparoscopic Heller myotomy (HM). We review in detail indications, outcomes, technique variations and comparative data between POEM and HM particularly with regard to the hotly debated issue of GERD. We then proceed to discuss two less illustrious but nevertheless important offshoots of the iconic POEM procedure: GPOEM for gastroparesis and ZPOEM for the treatment of hypopharyngeal diverticula. For GPOEM, we discuss the rationale of pylorus-directed therapies, briefly touch on GPOEM technique variations and then focus on the importance of proper patient selection and emerging data in this area. On the third and final part of our review, we discuss ZPOEM and expound on technique variations including our "ultra-short tunnel technique". Our review emphasizes that, despite the superiority of endoscopy over surgery for the treatment of hypopharyngeal diverticula, there is no clear evidence yet of the superiority of the newfangled ZPOEM technique compared to the conventional endoscopic myotomy technique practiced for over two decades prior to the advent of ZPOEM.
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Affiliation(s)
- Nasim Parsa
- Division of Gastroenterology and Hepatology, University of Missouri Health System, Columbia, MO, USA
| | - David Friedel
- Division of Gastroenterology, Hepatology and Nutrition, NYU-Winthrop Hospital, 222 Station Plaza N Suite 429, Mineola, NY, 11501, USA
| | - Stavros N Stavropoulos
- Division of Gastroenterology, Hepatology and Nutrition, NYU-Winthrop Hospital, 222 Station Plaza N Suite 429, Mineola, NY, 11501, USA.
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25
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Reja M, Mishra A, Tyberg A, Andalib I, Martínez GM, Zamarripa F, Gaidhane M, Nieto J, Kahaleh M. Gastric Peroral Endoscopic Myotomy: A Specific Learning Curve. J Clin Gastroenterol 2022; 56:339-342. [PMID: 34009842 DOI: 10.1097/mcg.0000000000001537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 02/18/2021] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Gastric peroral endoscopic pyloromyotomy (G-POEM) is a novel option for patients with gastroparesis. It involves submucosal tunneling across the pylorus, followed by pyloromyotomy, and subsequent closure of the endoscopic tunnel. The aim of this study was to determine the learning curve for G-POEM. METHODS Consecutive patients undergoing G-POEM by a single operator were included from a prospective registry over 2 years. Demographics, procedure info, postprocedure follow-up data, and adverse events were collected. Nonlinear regression and cumulative sum control chart analyses were conducted for the learning curve. Clinical outcomes were improvement in Gastroparesis Cardinal Symptom Index score and gastric emptying scintigraphy. RESULTS Thirty-six patients were included (16.7% M, mean age 46 y). The majority had idiopathic gastroparesis (n=16, 44%), with the remaining having diabetes (n=5, 17%), postsurgical (n=10, 28%), or other (n=4, 11%). Technical success was achieved in 35 of 36 (97%). There was a significant reduction in the total Gastroparesis Cardinal Symptom Index score (2.09 units, P<0.00001) and a significant reduction in postoperative gastric emptying scintigraphy (82.44 mins, P<0.00001). Mean follow-up was 15 months (SD, 1.05). Median procedure time was 60.5 minutes (range, 35 to 136). Cumulative sum control chart shows 60-minute procedure was achieved at the 18th procedure. Procedure durations further reduced with consequent procedures with the last 3 being 45 minutes, thus demonstrating continued improvement with ongoing experience (nonlinear regression P<0.0001). CONCLUSION Endoscopists experienced in G-POEM are expected to achieve a reduction in procedure time over successive cases, with efficiency reached at 60.5 minutes and a learning rate of 18 cases with continuing improvement.
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Affiliation(s)
- Mishal Reja
- Rutgers Robert Wood Johnson Medical School, New Brunswick
| | | | - Amy Tyberg
- Rutgers Robert Wood Johnson Medical School, New Brunswick
| | - Iman Andalib
- Ichan School of Medicine, Mount Sinai, New York, NY
| | | | | | | | | | - Michel Kahaleh
- Rutgers Robert Wood Johnson Medical School, New Brunswick
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Probiotics and Phytochemicals: Role on Gut Microbiota and Efficacy on Irritable Bowel Syndrome, Functional Dyspepsia, and Functional Constipation. GASTROINTESTINAL DISORDERS 2022. [DOI: 10.3390/gidisord4010005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Functional gastrointestinal disorders (FGIDs), such as irritable bowel syndrome, functional constipation, and functional dyspepsia, have had a high prevalence over the past few years. Recent evidence suggests that functional foods and bioactive compounds, such as probiotics and phytochemicals, may have a positive effect in treating the symptoms of the above diseases. In this systematic review study, 32 published studies were selected with the use of comprehensive scientific databases, according to PRISMA guidelines, with emphasis on recent interventional studies that reflect the effect of probiotics and selected phytochemicals on the improvement of FGID symptoms. The bioactive compounds in the selected studies were administered to patients either in capsule form or in enriched food products (yogurt, juice, etc.). According to the results, there is a correlation between the consumption of probiotics and phytochemicals, such as polyphenols, and the relief of symptoms in selected gastrointestinal disorders. Enriching foods that are regularly consumed by the population, such as fruit juices, yogurt, and cheese, with ingredients that may have a positive effect on gastrointestinal disorders, could be a possible novel goal for the management of these diseases. However, further evidence is required for the role of probiotics and phytochemicals in FGIDs to be fully understood.
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27
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Verga MC, Mazza S, Azzolini F, Cereatti F, Conti CB, Drago A, Soro S, Elvo B, Grassia R. Gastric per-oral endoscopic myotomy: Indications, technique, results and comparison with surgical approach. World J Gastrointest Surg 2022; 14:12-23. [PMID: 35126859 PMCID: PMC8790331 DOI: 10.4240/wjgs.v14.i1.12] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 07/20/2021] [Accepted: 12/23/2021] [Indexed: 02/06/2023] Open
Abstract
Gastroparesis is a chronic disease of the stomach that causes a delayed gastric emptying, without the presence of a stenosis. For 30 years the authors identified pylorospasm as one of the most important pathophysiological mechanisms determining gastroparesis. Studies with EndoFLIP, a device that assesses pyloric distensibility, increased the knowledge about pylorospasm. Based on this data, several pyloric-targeted therapies were developed to treat refractory gastroparesis: Surgical pyloroplasty and endoscopic approach, such as pyloric injection of botulinum and pyloric stenting. Notwithstanding, the success of most of these techniques is still not complete. In 2013, the first human gastric per-oral endoscopic myotomy (GPOEM) was performed. It was inspired by the POEM technique, with a similar dissection method, that allows pyloromyotomy. Therapeutical results of GPOEM are similar to surgical approach in term of clinical success, adverse events and post-surgical pain. In the last 8 years GPOEM has gained the attention of the scientific community, as a minimally invasive technique with high rate of clinical success, quickly prevailing as a promising therapy for gastroparesis. Not surprisingly, in referral centers, its technical success rate is 100%. One of the main goals of recent studies is to identify those patients that will respond better to the therapies targeted on pylorus and to choose the better approach for each patient.
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Affiliation(s)
- Maria Chiara Verga
- Gastroenterology and Digestive Endoscopy Unit, ASST Cremona, Cremona 26100, Italy
| | - Stefano Mazza
- Gastroenterology and Digestive Endoscopy Unit, ASST Cremona, Cremona 26100, Italy
| | - Francesco Azzolini
- Gastroenterology and Digestive Endoscopy Unit, Ospedale San Raffaele IRCCS, Milano 20132, Italy
| | - Fabrizio Cereatti
- Gastroenterology and Digestive Endoscopy Unit, ASST Cremona, Cremona 26100, Italy
| | | | - Andrea Drago
- Gastroenterology and Digestive Endoscopy Unit, ASST Cremona, Cremona 26100, Italy
| | - Sara Soro
- Gastroenterology and Digestive Endoscopy Unit, ASST Cremona, Cremona 26100, Italy
| | - Biagio Elvo
- Gastroenterology and Digestive Endoscopy Unit, ASST Cremona, Cremona 26100, Italy
| | - Roberto Grassia
- Gastroenterology and Digestive Endoscopy Unit, ASST Cremona, Cremona 26100, Italy
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28
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Camilleri M. Beyond Metoclopramide for Gastroparesis. Clin Gastroenterol Hepatol 2022; 20:19-24. [PMID: 34547280 PMCID: PMC8688280 DOI: 10.1016/j.cgh.2021.08.052] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 08/25/2021] [Accepted: 08/30/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
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29
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Abstract
Gastroparesis is characterized by symptoms suggestive of, and objective evidence of, delayed gastric emptying in the absence of mechanical obstruction. This review addresses the normal emptying of solids and liquids from the stomach and details the myogenic and neuromuscular control mechanisms, including the specialized function of the pyloric sphincter, that result in normal emptying, based predominantly on animal research. A clear understanding of fundamental mechanisms is necessary to comprehend derangements leading to gastroparesis, and additional research on human gastric muscles is needed. The section on pathophysiology of gastroparesis considers neuromuscular diseases that affect nonsphincteric gastric muscle, disorders of the extrinsic neural control, and pyloric dysfunction that lead to gastroparesis. The potential cellular basis for gastroparesis is attributed to the effects of oxidative stress and inflammation, with increased pro-inflammatory and decreased resident macrophages, as observed in full-thickness biopsies from patients with gastroparesis. Predominant diagnostic tests involving measurements of gastric emptying, the use of a functional luminal imaging probe, and high-resolution antral duodenal manometry in characterizing the abnormal motor functions at the gastroduodenal junction are discussed. Management is based on supporting nutrition; dietary interventions, including the physical reduction in particle size of solid foods; pharmacological agents, including prokinetics and anti-emetics; and interventions such as gastric electrical stimulation and pyloromyotomy. These are discussed briefly, and comment is added on the potential for individualized treatments in the future, based on optimal gastric emptying measurement and objective documentation of the underlying pathophysiology causing the gastroparesis.
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Affiliation(s)
- Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
| | - Kenton M. Sanders
- Department of Physiology and Cell Biology, University of Nevada, Reno School of Medicine, Reno, NV
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Huegle U, Dormann AJ. [G-POEM - Gastric Peroral Endoscopic Myotomy as a Therapy Option for Chronic Gastric Emptying Disorders]. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2021; 60:175-179. [PMID: 34820801 DOI: 10.1055/a-1676-4981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Many doctors and patients shy away from the surgical intervention of a pyloromyotomy using laparoscopy. The effectiveness of botulinum toxin injections into the pylorus has not been established 1 2. Pharmacological therapeutic approaches are unsatisfactory and show a wide range of side effects 3. G-POEM is a procedure that has proven its feasibility with a low complication rate. A relatively high response could be documented in previous publications 4. The long-term successes are still being discussed controversially 5. After the initial euphoria, the problem of patient selection comes to the fore. The symptoms, as well as the pathophysiology of gastric emptying disorder, are diverse 6. The diagnostic tests available do not reflect the variability of the disease 7 8 9 10. The postoperative gastric emptying disorder seems to be an exception. G-POEM can protect both therapists and patients from another invasive procedure.
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Affiliation(s)
- Ulrich Huegle
- Zentrum für Viszeralmedizin, Städtische Kliniken Köln, Cologne, Germany
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31
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Pioppo L, Reja D, Gaidhane M, Bareket R, Tawadros A, Madrigal Méndez AL, Nieto J, Zamarripa F, Martínez MG, Carames MC, Carames JC, Liu-Burdowski J, Kim M, Deshmukh AA, Suresh S, Alkhiari R, Andalib I, Shahid HM, Sarkar A, Tyberg A, Kahaleh M. Gastric per-oral endoscopic myotomy versus pyloromyotomy for gastroparesis: An international comparative study. J Gastroenterol Hepatol 2021; 36:3177-3182. [PMID: 34170565 DOI: 10.1111/jgh.15599] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 06/11/2021] [Accepted: 06/15/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIM Gastroparesis is a potentially debilitating gastric motility disorder with limited treatment options. Highest efficacy treatments include gastric per-oral endoscopic myotomy (GPOEM) and surgical pyloromyotomy. This study compares the efficacy and safety of GPOEM versus laparoscopic pyloromyotomy for refractory gastroparesis. METHODS Patients who underwent GPOEM or laparoscopic pyloromyotomy for refractory gastroparesis from four centers across the USA and Latin America were included in a dedicated registry. Data collected included patient demographics, imaging, laboratory values, clinical success, gastroparesis cardinal symptom index, procedure time, pre-op and post-op gastric emptying times, adverse events, and hospital length of stay. RESULTS A total of 102 patients were included (mean age 47; 32.4% male): GPOEM n = 39, surgical pyloromyotomy n = 63.Technical success was 100% in both groups. Clinical success was 92.3% in the GPOEM group and 82.5% in the surgery group (P = 0.164). The GPOEM group had a significantly higher post-op GSCI score reduction by 1.3 units (P < 0.00001), post-op retention reduction at 2 h by 18% (P < 0.00001), post-op retention reduction at 4 h by 25% (P < 0.00001) and a lower procedure time by 20 min (P < 0.00001) as compared with surgery. GPOEM also had a lower hospital length of stay by 2.8 days (P < 0.00001). Adverse events were significantly fewer in the GPOEM group (13%) compared with surgery group (33.3%; P = 0.021). Mean blood loss in the GPOEM group was only 3.6 mL compared with 866 mL in the surgery group. CONCLUSIONS The GPOEM may be a less invasive, safer, and more efficacious procedural treatment for refractory gastroparesis as compared with surgical pyloromyotomy.
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Affiliation(s)
- Lauren Pioppo
- Department of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson Medical School, Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Debashis Reja
- Department of Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Monica Gaidhane
- Department of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson Medical School, Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Romy Bareket
- Department of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson Medical School, Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Augustine Tawadros
- Department of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson Medical School, Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Ana L Madrigal Méndez
- Department of Gastroenterology, Costa Rican Social Security Fund, San José, Costa Rica
| | - Jose Nieto
- Department of Gastroenterology, Borland-Groover Clinic, Miami, Florida, USA
| | - Felipe Zamarripa
- Department of Gastroenterology, Juarez Hospital, Ciudad Juarez, Mexico
| | | | - Mine C Carames
- Department of Gastroenterology, Santander Hospital, Reynosa, Mexico
| | - Juan C Carames
- Department of Gastroenterology, Santander Hospital, Reynosa, Mexico
| | - Jennifer Liu-Burdowski
- Department of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson Medical School, Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Marina Kim
- Department of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson Medical School, Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Ameya A Deshmukh
- Department of Gastroenterology, Costa Rican Social Security Fund, San José, Costa Rica
| | - Supriya Suresh
- Department of Gastroenterology, Weill Cornell Medical College, New York, New York, USA
| | - Resheed Alkhiari
- Department of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson Medical School, Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | | | - Haroon M Shahid
- Department of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson Medical School, Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Avik Sarkar
- Department of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson Medical School, Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Amy Tyberg
- Department of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson Medical School, Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Michel Kahaleh
- Department of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson Medical School, Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
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Ukegjini K, Vetter D, Fehr R, Dirr V, Gubler C, Gutschow CA. Functional syndromes and symptom-orientated aftercare after esophagectomy. Langenbecks Arch Surg 2021; 406:2249-2261. [PMID: 34036407 PMCID: PMC8578083 DOI: 10.1007/s00423-021-02203-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 05/16/2021] [Indexed: 01/02/2023]
Abstract
BACKGROUND Surgery is the cornerstone of esophageal cancer treatment but remains burdened with significant postoperative changes of gastrointestinal function and quality of life. PURPOSE The aim of this narrative review is to assess and summarize the current knowledge on postoperative functional syndromes and quality of life after esophagectomy for cancer, and to provide orientation for the reader in the challenging field of functional aftercare. CONCLUSIONS Post-esophagectomy syndromes include various conditions such as dysphagia, reflux, delayed gastric emptying, dumping syndrome, weight loss, and chronic diarrhea. Clinical pictures and individual expressions are highly variable and may be extremely distressing for those affected. Therefore, in addition to a mostly well-coordinated oncological follow-up, we strongly emphasize the need for regular monitoring of physical well-being and gastrointestinal function. The prerequisite for an effective functional aftercare covering the whole spectrum of postoperative syndromes is a comprehensive knowledge of the pathophysiological background. As functional conditions often require a complex diagnostic workup and long-term therapy, close interdisciplinary cooperation with radiologists, gastroenterologists, oncologists, and specialized nutritional counseling is imperative for successful management.
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Affiliation(s)
- Kristjan Ukegjini
- Department of Visceral and Transplant Surgery, University Hospital Zurich, Zurich, Switzerland
- Department of General, Visceral, Endocrine and Transplant Surgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Diana Vetter
- Department of Visceral and Transplant Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Rebecca Fehr
- Department of Endocrinology, Diabetology and Clinical Nutrition, University Hospital Zurich, Zurich, Switzerland
| | - Valerian Dirr
- Department of Visceral and Transplant Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Christoph Gubler
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Christian A Gutschow
- Department of Visceral and Transplant Surgery, University Hospital Zurich, Zurich, Switzerland.
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Murray FR, Schindler V, Hente JM, Fischbach LM, Schnurre L, Deibel A, Hildenbrand FF, Tatu AM, Pohl D. Pyloric dilation with the esophageal functional lumen imaging probe in gastroparesis improves gastric emptying, pyloric distensibility, and symptoms. Gastrointest Endosc 2021; 94:486-494. [PMID: 33771556 DOI: 10.1016/j.gie.2021.03.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 03/14/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS The role of decreased pyloric distensibility in gastroparesis as measured by the endolumenal functional luminal imaging probe (EndoFLIP) has been receiving increasing attention. In this study, we present clinical outcomes to pyloric dilation with the esophageal FLIP (EsoFLIP) in regard to gastric emptying, symptom evolution, and FLIP metrics. METHODS Patients evaluated for gastroparesis (gastric emptying studies of t1/2 ≥180 minutes during 13C-octanoic acid breath test and/or gastric remnants during gastroscopy after a sufficient fasting period) were scheduled for EsoFLIP controlled pyloric dilation. Pre- and postprocedural gastric emptying studies, questionnaires (Patient Assessment of Upper GI Symptoms Severity Index [PAGI-SYM; including the Gastroparesis Cardinal Symptom Index] and Patient Assessment of Quality of Life Index [PAGI-QOL]), and FLIP metrics were documented. Dilation was conducted according to a self-developed algorithm. RESULTS Forty-six patients were analyzed (72% women; median age, 39 years [range, 18-88]). Etiologies of gastroparesis were diabetic in 10 patients (22%), idiopathic in 33 (72%), and postoperative in 3 (6%). Postprocedural gastric emptying time decreased from a median of 211 minutes to 179 minutes (P = .001). In accordance, pyloric distensibility, PAGI-SYM, PAGI-QOL, and Gastroparesis Cardinal Symptom Index values improved significantly. After a median follow-up of 3.9 months, 57% of all treated patients with returned questionnaires reported improved symptoms. CONCLUSIONS Pyloric EsoFLIP controlled dilation shows value in the treatment of gastroparesis, both subjectively and objectively. Long-term follow-up to assess efficacy and comparative trials are warranted.
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Affiliation(s)
- Fritz Ruprecht Murray
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Valeria Schindler
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Juliane Marie Hente
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Lara Maria Fischbach
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Larissa Schnurre
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Ansgar Deibel
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | | | - Aurora Maria Tatu
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Daniel Pohl
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
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Saleem S, Hussain A, Alsamman MA, Inayat F, Kaler J, Tansel A, Thomas AL. Characteristics of patients who underwent gastric electrical stimulation vs. surgical pyloric interventions for refractory gastroparesis. Saudi J Gastroenterol 2021; 27:309-315. [PMID: 34380871 PMCID: PMC8555767 DOI: 10.4103/sjg.sjg_673_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND There has been recent debate comparing the efficacy of gastric electrical stimulation (GES) with pyloric intervention, but medical literature lacks clear indications for when to perform GES or pyloric intervention. This study aims to assess the effect of sociodemographic factors and hospital characteristics on the surgical technique chosen for the treatment of gastroparesis. METHODS Data was extracted from the National Inpatient Sample between the years 2012 and 2014, using any discharge diagnosis of gastroparesis. For comparison of analysis between GES and pyloric surgical intervention, pyloroplasty, endoscopic pyloric dilation, and pyloromyotomy were considered to be pyloric interventions. The study population was divided into two groups, one which received GES and the other receiving pyloric intervention, to compare socioeconomic factors and hospital characteristics. RESULTS In total, 737,930 hospitalizations had a discharge diagnosis of gastroparesis between 2012 and 2014. On weighted multivariant analysis of patients undergoing GES or pyloric intervention for gastroparesis, being female (odds ratio (OR) 1.49, 95% confidence interval (CI) 1.25-1.78; P < 0.001), being Hispanic (OR 1.75, 95%CI; P < 0.001), being in urban teaching (OR 1.41, 95%CI 1.15-1.72; P < 0.001), and nonteaching hospitals (OR 2.93, 95%CI 2.4-3.58; P < 0.001), early satiety (OR 6.70, 95%CI 1.54-31.25; P = 0.01), and diabetes mellitus (OR 2.14, 95%CI 1.78-2.56; P < 0.001) were each statistically significantly correlated with receiving GES intervention compared to pyloric intervention. CONCLUSION The racial difference, payer source, and hospital location affected the surgical intervention (GES or pyloric intervention) that patients with gastroparesis would receive.
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Affiliation(s)
- Saad Saleem
- Department of Internal Medicine, Sunrise Hospital and Medical Center, Las Vegas, NV, United States,Address for correspondence: Dr. Saad Saleem, 3186 S Maryland parkway, Las Vegas, Nevada - 89109, United States. E-mail:
| | - Azhar Hussain
- Department of Internal Medicine, SUNY Downstate Medical Center, Brooklyn, NY, United States
| | - Mohd A. Alsamman
- Department of Gastroenterology, Georgetown University, Washington, D.C, United States
| | - Faisal Inayat
- Department of Internal Medicine, Allama Iqbal Medical College, Lahore, Pakistan
| | - Jasndeep Kaler
- Department of Internal Medicine, Xavier University School of Medicine, Oranjestad, Aruba
| | - Aylin Tansel
- Department of Gastroenterology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Abell L. Thomas
- Department of Gastroenterology, University of Louisville, KY, United States
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Abstract
Until recently, gastric motility measurements in humans were mostly limited to accommodation (using barostat or 3-dimensional imaging studies of gastric volume) and gastric emptying tests, the latter being the only one performed in routine clinical care. Accurate and easy to use techniques were lacking to assess pyloric function in health and disease. Recently, pyloric distensibility has been developed and validated to assess pyloric opening. Several studies confirmed that pyloric distensibility was decreased in gastroparesis and correlated with gastric emptying as well as gastroparesis symptoms. In addition, pyloric distensibility may predict outcome of endoscopic techniques targeting the pylorus, namely intrapyloric botulinum toxin injection and gastric per-oral pyloromyotomy. Pyloric distensibility appears therefore to be a promising and useful new tool in the workup of gastroparesis patients.
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Affiliation(s)
- Fabien Wuestenberghs
- Department of Physiology, Institut National de la Santé et de la Recherche Médicale Unit 1073 and Clinical Investigation Centre-Centre de Ressource Biologiqu 1404, Rouen University Hospital, UNIROUEN, Normandie University, Rouen, France.,Department of Gastroenterology and Hepatology, Centre Hospitalier Universitaire UCLouvain Namur, Godinne University Hospital, UCLouvain, Yvoir, Belgium
| | - Guillaume Gourcerol
- Department of Physiology, Institut National de la Santé et de la Recherche Médicale Unit 1073 and Clinical Investigation Centre-Centre de Ressource Biologiqu 1404, Rouen University Hospital, UNIROUEN, Normandie University, Rouen, France
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Lin J, Liu G, Duan Z. The mechanism of esophagus dysmotility in diabetes and research progress of relating treatments. Expert Rev Gastroenterol Hepatol 2021; 15:919-927. [PMID: 34156876 DOI: 10.1080/17474124.2021.1945921] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Esophagus dysmotility is a crucial risk factor of gastroesophageal reflux disease (GERD), which is one of the most common diseases in digestive medicine globally. This review emphasizes the mechanisms of esophagus dysmotility in diabetes and summarizes more targeted treatments for these patients to avoid the overuse of proton pump inhibitors (PPIs).Areas covered: Diabetes mellitus (DM) is a clear factor that must not be neglected in the development of GERD. Previous studies have preliminarily researched the esophagus deterioration in diabetes. However, the multi-faceted mechanisms of esophagus dysmotility in diabetes need more studies. Besides, targeted treatments for these patients rather than conventional PPIs are urgently needed.Expert opinion: The treatments for GERD patients with diabetes should be further explored. Pharmacological approaches such as prokinetic agents, psychotherapy can be adopted. Meanwhile, it's feasible to explore non-drug treatments. For example, Electroacupuncture (EA) at Zusanli (ST-36) may be effective to protect the networks of intestinal cells of Cajal (ICCs) in diabetes. More effective approaches should be explored to achieve individualized treatment for these patients.
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Affiliation(s)
- Jiarong Lin
- The Second Department of Gastroenterology, The First Affiliated Hospital of Dalian Medical University, Dalian, China.,Laboratory of Integrated Chinese and Western Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Gongkai Liu
- School of Medicine, Nova Southeastern University, Davie, FL, USA
| | - Zhijun Duan
- The Second Department of Gastroenterology, The First Affiliated Hospital of Dalian Medical University, Dalian, China.,Laboratory of Integrated Chinese and Western Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian, China
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Jehangir A, Malik Z, Petrov RV, Parkman HP. EndoFLIP and Pyloric Dilation for Gastroparesis Symptoms Refractory to Pyloromyotomy/Pyloroplasty. Dig Dis Sci 2021; 66:2682-2690. [PMID: 32749636 DOI: 10.1007/s10620-020-06510-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 07/21/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Gastroparesis patients may undergo pyloromyotomy/pyloroplasty for chronic refractory symptoms. However, some patients have persistent symptoms. It is unknown if balloon dilation may improve their symptoms. AIMS We aimed to (1) assess if pyloric through-the-scope (TTS) balloon dilation results in symptom improvement in gastroparesis patients with suboptimal response to pyloromyotomy/pyloroplasty and (2) determine endoscopic functional luminal imaging probe (EndoFLIP) characteristics of these patients before dilation. METHODS Patients with severe gastroparesis refractory to pyloromyotomy/pyloroplasty seen from 2/2019 to 3/2020 underwent pyloric TTS dilation after assessing the pyloric characteristics using EndoFLIP. Patients completed Gastroparesis Cardinal Symptom Index (GCSI) pre-procedurally, and GCSI and Clinical Patient Grading Assessment Scale (CPGAS) on follow-ups. RESULTS Thirteen (ten females) patients (mean age 45.2 ± 5.1 years) with severe gastroparesis symptoms (mean GCSI total score 3.4 ± 0.3) after pyloromyotomy/pyloroplasty underwent pyloric TTS dilation. Overall, there was improvement in symptoms at 1-month follow-up (mean GCSI total score 3.0 ± 0.4, mean CPGAS score 1.6 ± 0.5, p < 0.05 for both), with five (38%) patients reporting symptoms somewhat/moderately better. The patients with symptom improvement had lower pre-dilation pyloric EndoFLIP distensibility at 30 ml, 40 ml, and 50 ml than patients with little/no improvement (all p < 0.05). CONCLUSIONS In gastroparesis patients with refractory symptoms after pyloromyotomy/pyloroplasty, pyloric TTS dilation improved symptoms in about a third of the patients. Patients with symptom improvement had lower pre-dilation pyloric distensibility on EndoFLIP suggesting incomplete myotomy, pyloric muscle regeneration, or pyloric stricture. Pyloric EndoFLIP followed by TTS dilation seems to be a promising treatment for some patients with gastroparesis symptoms refractory to pyloromyotomy/pyloroplasty.
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Affiliation(s)
- Asad Jehangir
- Gastroenterology Section, Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA
| | - Zubair Malik
- Gastroenterology Section, Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA
| | - Roman V Petrov
- Department of Thoracic Surgery, Temple University School of Medicine, Philadelphia, PA, USA
| | - Henry P Parkman
- Gastroenterology Section, Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA.
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Ragi O, Jacques J, Branche J, Leblanc S, Vanbiervliet G, Legros R, Pioche M, Rivory J, Chaussade S, Barret M, Wallenhorst T, Barthet M, Kerever S, Gonzalez JM. One-year results of gastric peroral endoscopic myotomy for refractory gastroparesis: a French multicenter study. Endoscopy 2021; 53:480-490. [PMID: 32575130 DOI: 10.1055/a-1205-5686] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Data on the long-term outcomes of gastric peroral endoscopic myotomy (G-POEM) for refractory gastroparesis are lacking. We report the results of a large multicenter long-term follow-up study of G-POEM for refractory gastroparesis. METHODS This was a retrospective multicenter study of all G-POEM operations performed in seven expert French centers for refractory gastroparesis with at least 1 year of follow-up. The primary endpoint was the 1-year clinical success rate, defined as at least a 1-point improvement in the Gastroparesis Cardinal Symptom Index (GCSI). RESULTS 76 patients were included (60.5 % women; age 56 years). The median symptom duration was 48 months. The median gastric retention at 4 hours (H4) before G-POEM was 45 % (interquartile range [IQR] 29 % - 67 %). The median GCSI before G-POEM was 3.6 (IQR 2.8 - 4.0). Clinical success was achieved in 65.8 % of the patients at 1 year, with a median rate of reduction in the GCSI score of 41 %. In logistic regression analysis, only a high preoperative GCSI satiety subscale score was predictive of clinical success (odds ratio [OR] 3.41, 95 % confidence interval [CI] 1.01 - 11.54; P = 0.048), while a high rate of gastric retention at H4 was significantly associated with clinical failure (OR 0.97, 95 %CI 0.95 - 1.00; P = 0.03). CONCLUSIONS The results confirm the efficacy of G-POEM for the treatment of refractory gastroparesis, as evidenced by a 65.8 % clinical success rate at 1 year. Although G-POEM is promising, prospective sham-controlled trials are urgently needed to confirm its efficacy and identify the patient populations who will benefit most from this procedure.
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Affiliation(s)
- Olivier Ragi
- Service de gastroentérologie, CHU Limoges, France
| | - Jérémie Jacques
- Service de gastroentérologie, CHU Limoges, France.,CNRS, XLIM, UMR 7252, Limoges, France
| | - Julien Branche
- Service de gastroentérologie, CHU Claude Huriez, Lille, France
| | - Sarah Leblanc
- Service de gastroentérologie, APHP, Hôpital Cochin, Paris, France
| | | | | | - Mathieu Pioche
- Service de gastroentérologie, HCL Edouard Herriot, Lyon, France
| | - Jérôme Rivory
- Service de gastroentérologie, HCL Edouard Herriot, Lyon, France
| | | | | | | | - Marc Barthet
- Service de gastroentérologie, APHM, Hôpital Nord, Marseille, France
| | - Sébastien Kerever
- Department of Anesthesiology and Critical Care, Saint Louis Lariboisière Fernand Widal University Hospital, AP-HP, Paris, France
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Li P, Ma B, Gong S, Zhang X, Li W. Gastric per-Oral Endoscopic Myotomy for Refractory Gastroparesis: A Meta-Analysis. J Gastrointest Surg 2021; 25:1108-1116. [PMID: 32394124 DOI: 10.1007/s11605-020-04520-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Accepted: 01/14/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND The emerging gastric per-oral endoscopic myotomy (G-POEM) is becoming an alternative treatment method for gastroparesis. This study aimed to evaluate the feasibility and safety of G-POEM for gastroparesis. METHODS Relevant publications were identified through searching PubMed, EMBASE, Cochrane Library, and Web of Science before April 1, 2019. Studies presenting the clinical data of G-POEM for the treatment of gastroparesis were included. Data about effectiveness and safety were extracted, pooled, and analyzed. Forest plots were graphed based on random effects models. RESULTS A total of 272 patients representing 8 studies were eligible for analysis. The pooled rates of GCSI at preprocedure, 1-3 months, 6 months, and 12 months, were 3.25 (95% CI, 2.75-3.75), 1.80 (95% CI, 1.10-2.49), 1.56 (95% CI, 0.45-2.68), and 1.10 (95% CI, 0.75-1.45), respectively. The pooled results of 4-h GES pre- and post-G-POEM were 41.89% (95% CI, 32.75-51.03%) and 16.48% (95% CI, 9.83-23.14%), respectively. Furthermore, the pooled clinical response rate was 84% (95% CI, 77-89%). The GES improvement rate and GES normal rate were also analyzed, and the results were 84% (95% CI, 77-90%) and 53% (95% CI, 39-66%), respectively. Finally, the pooled adverse events rate was 12% (95% CI, 6-19%). CONCLUSIONS G-POEM was shown to be feasible and safe for the treatment of gastroparesis with various etiologies, which could be a potential first-line therapy for certain patients. Future studies are needed to investigate the appropriate patients for G-POEM to explore the "most beneficial" subgroup of patients.
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Affiliation(s)
- Peiwen Li
- Department of Thoracic Surgery, The First Hospital of China Medical University, No.155 North Nanjing Street, Shenyang, 110001, People's Republic of China
| | - Bin Ma
- Department of Colorectal Surgery, Liaoning Cancer Hospital and Institute, Cancer Hospital of China Medical University, No. 44 Xiaoheyan Road, Dadong District, Shenyang, 110042, Liaoning Province, People's Republic of China
| | - Shulei Gong
- Department of Thoracic Surgery, The First Hospital of China Medical University, No.155 North Nanjing Street, Shenyang, 110001, People's Republic of China
| | - Xinyu Zhang
- Department of Thoracic Surgery, The First Hospital of China Medical University, No.155 North Nanjing Street, Shenyang, 110001, People's Republic of China
| | - Wenya Li
- Department of Thoracic Surgery, The First Hospital of China Medical University, No.155 North Nanjing Street, Shenyang, 110001, People's Republic of China.
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Longley KJ, Ho V. Practical management approach to gastroparesis. Intern Med J 2021; 50:909-917. [PMID: 31314176 DOI: 10.1111/imj.14438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 06/16/2019] [Accepted: 07/04/2019] [Indexed: 11/27/2022]
Abstract
Gastroparesis is a syndrome characterised by delayed gastric emptying in the absence of mechanical obstruction. Symptoms can include early satiety, abdominal pain, bloating, vomiting and regurgitation which cause significant morbidity in addition to nutritional deficits. There is a higher prevalence in diabetics and females, but the incidence in the Australian population has not been well studied. Management of gastroparesis involves investigating and correcting nutritional deficits, optimising glycaemic control and improving gastrointestinal motility. Symptom control in gastroparesis can be challenging. Nutritional deficits should be addressed initially through dietary modification. Enteral feeding is a second-line option when oral intake is insufficient. Home parenteral nutrition is rarely used, and only accessible through specialised clinics in the outpatient setting. Prokinetic medication classes that have been used include dopamine receptor antagonists, motilin receptor agonists, 5-HT4 receptor agonists and ghrelin receptor agonists. Anti-emetic agents are often used for symptom control. Interventional treatments include gastric electrical stimulation, gastric per-oral endoscopic myotomy, feeding jejunostomy and gastrostomy/jejunstomy for gastric venting and enteral feeding. In this article we propose a framework to manage gastroparesis in Australia based on current evidence and available therapies.
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Affiliation(s)
- Kieran J Longley
- Department of Medicine, Campbelltown Hospital, Sydney, New South Wales, Australia
| | - Vincent Ho
- Gastroenterology, Campbelltown Hospital, Sydney, New South Wales, Australia.,School of Medicine, Western Sydney University, Sydney, New South Wales, Australia
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Petrov RV, Fajardo RA, Bakhos CT, Abbas AE. Peroral endoscopic myotomy: techniques and outcomes. ACTA ACUST UNITED AC 2021; 5. [PMID: 34013165 DOI: 10.21037/shc.2020.02.02] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Achalasia is progressive neurodegenerative disorder of the esophagus, resulting in uncoordinated esophageal motility and failure of lower esophageal sphincter relaxation, leading to impaired swallowing. Surgical myotomy of the lower esophageal sphincter, either open or minimally invasive, has been a standard of care for the past several decades. Recently, new procedure-peroral endoscopic myotomy (POEM) has been introduced into clinical practice. This procedure accomplishes the same objective of controlled myotomy only via endoscopic approach. In the current chapter authors review the present state, clinical applications, outcomes and future directions of the POEM procedure.
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Affiliation(s)
- Roman V Petrov
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Romulo A Fajardo
- Department of General Surgery, Temple University Hospital. Philadelphia, PA, USA
| | - Charles T Bakhos
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Abbas E Abbas
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
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Abdelfatah MM, Noll A, Kapil N, Shah R, Li L, Nustas R, Li B, Luo H, Chen H, Xia L, Mekaroonkamol P, Shahnavaz N, Keilin S, Willingham F, Christie J, Cai Q. Long-term Outcome of Gastric Per-Oral Endoscopic Pyloromyotomy in Treatment of Gastroparesis. Clin Gastroenterol Hepatol 2021; 19:816-824. [PMID: 32450364 DOI: 10.1016/j.cgh.2020.05.039] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 05/15/2020] [Accepted: 05/18/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Gastric per oral endoscopic pyloromyotomy (GPOEM) is a promising treatment for gastroparesis. There are few data on the long-term outcomes of this procedure. We investigated long-term outcomes of GPOEM treatment of patients with refractory gastroparesis. METHODS We conducted a retrospective case-series study of all patients who underwent GPOEM for refractory gastroparesis at a single center (n = 97), from June 2015 through March 2019; 90 patients had more than 3 months follow-up data and were included in our final analysis. We collected data on gastroparesis cardinal symptom index (GCSI) scores (measurements of postprandial fullness or early satiety, nausea and vomiting, and bloating) and SF-36 questionnaire scores (measures quality of life). The primary outcome was clinical response to GPOEM, defined as a decrease of at least 1 point in the average total GCSI score with more than a 25% decrease in at least 2 subscales of cardinal symptoms. Recurrence was defined as a return to baseline GCSI or GCSI scores of 3 or more for at least 2 months after an initial complete response. The secondary outcome was the factors that predict GPOEM failure (no response or gastroparesis recurrence within 6 months). RESULTS At initial follow-up (3 to 6 months after GPOEM), 73 patients (81.1%) had a clinical response and significant increases in SF-36 questionnaire scores (indicating increased quality of life) whereas 17 patients (18.9%) had no response. Six months after GPOEM, 7.1% had recurrence. At 12 months, 8.3% of patients remaining in the study had recurrence. At 24 months, 4.8% of patients remaining in the study had a recurrence. At 36 months, 14.3% of patients remaining in the study had recurrence. For patients who experienced an initial clinical response, the rate of loss of that response per year was 12.9%. In the univariate and multivariate regression analysis, a longer duration of gastroparesis reduced the odds of response to GPOEM (odds ratio [OR], 0.092; 95% CI, 1.04-1.3; P = .001). On multivariate logistic regression, patients with high BMIs had increased odds of GPOEM failure (OR, 1.097; 95% CI, 1.022-1.176; P = .010) and patients receiving psychiatric medications had a higher risk of GPOEM failure (OR, 1.33; 95% CI, 0.110-1.008; P = .052). CONCLUSIONS In retrospective analysis of 90 patients who underwent GPOEM for refractory gastroparesis, 81.1% had a clinical response at initial follow-up of their procedure. 1 year after GPOEM, 69.1% of all patients had a clinical response and 85.2% of initial responders maintained a clinical response. Patients maintained a clinical response and improved quality of life for as long as 3 years after the procedure. High BMI and long duration gastroparesis were associated with failure of GPOEM.
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Affiliation(s)
- Mohamed M Abdelfatah
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Alan Noll
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Neil Kapil
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Rushikesh Shah
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Lianyong Li
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Rosemary Nustas
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Baiwen Li
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Hui Luo
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Huimin Chen
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Liang Xia
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Parit Mekaroonkamol
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Nikrad Shahnavaz
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Steven Keilin
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Field Willingham
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Jennifer Christie
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Qiang Cai
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia.
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Conchillo JM, Straathof JWA, Mujagic Z, Brouns JH, Bouvy ND, Keszthelyi D, Masclee AA. Gastric peroral endoscopic pyloromyotomy for decompensated gastroparesis: comprehensive motility analysis in relation to treatment outcomes. Endosc Int Open 2021; 9:E137-E144. [PMID: 33532550 PMCID: PMC7834704 DOI: 10.1055/a-1311-0859] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 10/05/2020] [Indexed: 12/26/2022] Open
Abstract
Background and study aims There are no reliable data to predict which patients with gastroparesis (GP) would benefit the most from gastric peroral endoscopic pyloromyotomy (G-POEM). The aim of the present study was to assess whether antro-duodenal motility patterns and pyloric distensibility can predict the outcome of G-POEM in patients with decompensated GP. Patients and methods In an open-label study, patients with GP and refractory symptoms were eligible for treatment with G-POEM if treatment attempts according to a standardized stepwise protocol had failed. Baseline assessment included Gastroparesis Cardinal Symptom Index (GCSI), C13-octanoic gastric emptying breath test and high-resolution antro-duodenal manometry. Pyloric distensibility using EndoFlip measurements was assessed at baseline and 3 months after the procedure. Explorative analyses were performed on potential predictors of response using logistic regression analyses. Results Twenty-four patients with decompensated GP underwent G-POEM. At baseline, 78.3 % and 61.9 % of patients showed antral hypomotility and neuropathic motor patterns, respectively. The technical success rate was 100 % (24/24). Mean GCSI improved significantly at 3, 6, and 12 months after G-POEM ( P = 0.01). Median distensibility index (DI) improved significantly as compared with baseline (7.5 [6.9;11.7] vs. 5.3[3.1;8.1], P = 0.004). A significant correlation was found between clinical response at 6 months and pyloric DI improvement ( P = 0.003). No potential predictors of clinical response after G-POEM could be identified in an explorative analysis. Conclusions G-POEM improved pyloric distensibility patterns in patients with decompensated GP. Clinical response at 6 months after G-POEM was associated with pyloric distensibility improvement. However, no potential predictors of response could be identified from either antro-duodenal motility patterns or pyloric distensibility.
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Affiliation(s)
- José M. Conchillo
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Jan Willem A. Straathof
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Zlatan Mujagic
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Jenny H. Brouns
- Department of Dietetics, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Nicole D. Bouvy
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Daniel Keszthelyi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Ad A.M. Masclee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
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Fathalizadeh A, Klingler M, Landreneau J, Allemang M, Rodriguez J, Ponsky J, El-Hayek K. Real-time intraoperative functioning lumen imaging probe during endoscopic per-oral pyloromyotomy (pop). Surg Endosc 2021; 36:745-752. [PMID: 33427911 PMCID: PMC8741673 DOI: 10.1007/s00464-020-08237-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Accepted: 12/08/2020] [Indexed: 01/12/2023]
Abstract
Background Endoscopic per-oral pyloromyotomy (POP) has emerged as a safe and effective first line option in medically refractory gastroparesis. Determining the appropriate extent of the pyloromyotomy continues to present a challenge as there are no standardized tools for measuring changes in pyloric distensibility during the procedure. The objective of this study was to evaluate the utility of using impedance planimetry with endoscopic functional luminal imaging probe (FLIP) to measure changes in pyloric distensibility after POP, and to compare these changes with improvement in symptoms and objective gastric emptying. Methods Patients with medically refractory gastroparesis underwent POP with FLIP measurements of the pylorus (EndoFLIP®, Medtronic, Fridley MN). FLIP measurements, as well as changes in symptoms measured by the validated gastroparesis cardinal symptom index (GCSI) and scintigraphic gastric emptying studies (GES), were evaluated before and after POP. Results A total of 14 patients underwent measurement with FLIP during POP, 12 of whom had pre- and post-POP measurements. Mean pyloric diameter increased by 1.4 mm, from 13.9 mm to 15.3 mm (p = 0.0012). Mean distensibility index increased from 6.2 mm2/mmHg to 9.1 mm2/mmHg (p = 0.0074). Successful division of the pylorus was achieved in 100% of patients with a mean operative time of 36 min and no perioperative complications. The mean length of stay was 0.7 days (0–3 days). Post-POP mean GCSI score improved from 2.97 to 2.28 at a mean follow-up time of 27 days (p < 0.001). Objective improvement in gastric emptying was observed in 80% of patients with scintigraphic GES, with mean four-hour retention decreasing from 46.3% to 32.4% (p < 0.007). Conclusions FLIP is a safe and feasible tool to provide objective measurements during POP. Larger cohorts with longer follow-up are required to determine if measured improvements in pyloric diameter and distensibility are predictive of sustained improvements in GCSI and GES.
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Affiliation(s)
- Alisan Fathalizadeh
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Michael Klingler
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Joshua Landreneau
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Matthew Allemang
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - John Rodriguez
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.,Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Jeffrey Ponsky
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.,Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Kevin El-Hayek
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.,Division of General Surgery, MetroHealth System, Cleveland, OH, USA.,Case Western Reserve University School of Medicine, Cleveland, OH, USA
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Per Oral Pyloromyotomy for Gastroparesis: A Systematic Review of the Current Literature and Future Recommendations. GASTROINTESTINAL DISORDERS 2020. [DOI: 10.3390/gidisord2040038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background: Gastric per oral endoscopic myotomy (GPOEM) was developed as a therapeutic option for gastroparesis after the pylorus was identified as a key target for gastroparesis management. This study includes a systematic literature review of studies in which GPOEM was utilized as therapy for gastroparesis. Methods: A literature search was conducted in three databases (MEDLINE, Scopus and Embase) of articles that included the keywords “GPOEM”, “Gastric per oral endoscopy myotomy” or “per oral pyloromyotomy” and “Gastroparesis” in the abstract or title. The search covered articles published until 29 February 2020. Results: A total of 139 articles were identified. Only 15 articles met the final inclusion criteria and were retrieved for qualitative data synthesis. Conclusion: GPOEM for gastroparesis is shown to have a high success rate among the studies but data interpretations are limited because of small sample sizes and short follow-up. Subjective and objective data prior to and post-GPOEM will be mandatory to establish credibility. The procedure is technically feasible and safe based on the limited studies available.
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Gastric peroral endoscopic myotomy (G-POEM) for refractory gastroparesis: 3-month follow-up results. Dig Liver Dis 2020; 52:1215-1218. [PMID: 32819858 DOI: 10.1016/j.dld.2020.07.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 07/21/2020] [Accepted: 07/22/2020] [Indexed: 12/11/2022]
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Parsi MA, Jirapinyo P, Abu Dayyeh BK, Bhutani MS, Chandrasekhara V, Krishnan K, Kumta NA, Melson J, Pannala R, Trikudanathan G, Trindade AJ, Sethi A, Watson RR, Maple JT, Lichtenstein DR. Techniques and devices for the endoscopic treatment of gastroparesis (with video). Gastrointest Endosc 2020; 92:483-491. [PMID: 32684298 DOI: 10.1016/j.gie.2020.03.3857] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 03/30/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Gastroparesis is a symptomatic chronic disorder of the stomach characterized by delayed gastric emptying in the absence of mechanical obstruction. Several endoscopic treatment modalities have been described that aim to improve gastric emptying and/or symptoms associated with gastroparesis refractory to dietary and pharmacologic management. METHODS In this report we review devices and techniques for endoscopic treatment of gastroparesis, the evidence regarding their efficacy and safety, and the financial considerations for their use. RESULTS Endoscopic modalities for treatment of gastroparesis can be broadly categorized into pyloric, nonpyloric, and nutritional therapies. Pyloric therapies such as botulinum toxin injection, stent placement, pyloroplasty, and pyloromyotomy specifically focus on pylorospasm as a therapeutic target. These interventions aim to reduce the pressure gradient across the pyloric sphincter, with a resultant improvement in gastric emptying. Nonpyloric therapies, such as venting gastrostomy and gastric electrical stimulation, are intended to improve symptoms. Nutritional therapies, such as feeding tube placement, aim to provide nutritional support. CONCLUSIONS Several endoscopic interventions have shown utility in improving the quality of life and symptoms of select patients with refractory gastroparesis. Methods to identify which patients are best suited for a specific treatment are not well established. Endoscopic pyloromyotomy is a relatively recent development that may prove to be the preferred pyloric-directed intervention, although additional and longer-term outcomes are needed.
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Affiliation(s)
- Mansour A Parsi
- Section for Gastroenterology and Hepatology, Tulane University Health Sciences Center, New Orleans, Louisiana, USA
| | - Pichamol Jirapinyo
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Barham K Abu Dayyeh
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Manoop S Bhutani
- Department of Gastroenterology Hepatology and Nutrition, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Vinay Chandrasekhara
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kumar Krishnan
- Division of Gastroenterology, Department of Internal Medicine, Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Nikhil A Kumta
- Division of Gastroenterology, Mount Sinai Hospital, New York, New York, USA
| | - Joshua Melson
- Division of Gastroenterology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Rahul Pannala
- Division of Digestive Diseases, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Guru Trikudanathan
- Department of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Arvind J Trindade
- Department of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
| | - Amrita Sethi
- Department of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, New Hyde Park, New York, USA
| | - Rabindra R Watson
- New York-Presbyterian Medical Center/Columbia University Medical Center, New York, New York, USA
| | - John T Maple
- Department of Gastroenterology, Interventional Endoscopy Services, California Pacific Medical Center, San Francisco, California, USA
| | - David R Lichtenstein
- Division of Digestive Diseases and Nutrition, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
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Endoscopic and Surgical Treatments for Gastroparesis: What to Do and Whom to Treat? Gastroenterol Clin North Am 2020; 49:539-556. [PMID: 32718569 PMCID: PMC7391056 DOI: 10.1016/j.gtc.2020.04.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Gastroparesis is a complex chronic debilitating condition of gastric motility resulting in the delayed gastric emptying and multiple severe symptoms, which may lead to malnutrition and dehydration. Initial management of patients with gastroparesis focuses on the diet, lifestyle modification and medical therapy. Various endoscopic and surgical interventions are reserved for refractory cases of gastroparesis, not responding to conservative therapy. Pyloric interventions, enteral access tubes, gastric electrical stimulator and gastrectomy have been described in the care of patients with gastroparesis. In this article, the authors review current management, indications, and contraindications to these procedures.
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Camilleri M, Sanders KM. Opiates, the Pylorus, and Gastroparesis. Gastroenterology 2020; 159:414-421. [PMID: 32389662 DOI: 10.1053/j.gastro.2020.04.072] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 04/14/2020] [Accepted: 04/16/2020] [Indexed: 02/07/2023]
Affiliation(s)
- Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Kenton M Sanders
- Department of Physiology and Cell Biology, University of Nevada, Reno School of Medicine, Reno, Nevada
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Brown AM, Pryor AD, Docimo S. Per oral pyloromyotomy utilizing a lesser curvature approach: how we do it. Surg Endosc 2020; 34:5168-5171. [DOI: 10.1007/s00464-020-07802-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 07/07/2020] [Indexed: 12/17/2022]
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