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Uemura KL, Chaves D, Bernardo WM, Uemura RS, de Moura DTH, de Moura EGH. Peroral endoscopic pyloromyotomy for gastroparesis: a systematic review and meta-analysis. Endosc Int Open 2020; 8:E911-E923. [PMID: 32617395 PMCID: PMC7297609 DOI: 10.1055/a-1119-6616] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 01/06/2020] [Indexed: 02/07/2023] Open
Abstract
Background and aim Gastric peroral endoscopic pyloromyotomy (G-POEM) is a new therapeutic option for refractory gastroparesis (GP). A systematic review and meta-analysis was conducted to assess the effectiveness of G-POEM in refractory GP. For the quality of evidence, we used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. Methods We performed a literature search using MEDLINE, Embase, Cochrane library, LILACS and the Science citation index for studies related to G-POEM from the inception of its technique through January 2019. We selected studies that analyzed the gastroparesis cardinal symptom index (GCSI) and 4-hour solid-phase gastric emptying scintigraphy (GES) before and after the procedure to verify the efficacy of G-POEM, the main outcome measured. An analysis was performed using RevMan 5.3. Results Ten studies comprising 281 patients were included in this systematic review. The pooled mean difference in GCSI following the procedure was 1.76 (95 % CI: [1.43, 2.08], I 2 = 72 %). We also performed GCSI subgroup analysis by follow-up duration that showed a pooled mean difference of 1.84 (95 % CI: [1.57, 2.12], I 2 = 71 %). The pooled mean difference in GES after the procedure was 26.28 (95 % CI: [19.74, 32.83], I 2 = 87 %), corresponding to a significant drop in percentage values of the gastric retention 4-hour scintigraphy. Conclusion This meta-analysis demonstrates that G-POEM is effective and shows promising outcomes in the clinical response and gastric emptying scintigraphy for gastroparesis. Therefore, it should be considered in the management of refractory gastroparesis.
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Affiliation(s)
- Karime Lucas Uemura
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Dalton Chaves
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Wanderley M. Bernardo
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Ricardo Sato Uemura
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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Vosoughi K, Ichkhanian Y, Jacques J, Aadam AA, Benias PC, Law R, Hasler WL, Canakis A, Ragi O, Triggs J, Bowers N, Brewer Gutierrez OI, Kumbhari V, Kalloo AN, Bulat RS, Pandolfino JE, Khashab MA. Role of endoscopic functional luminal imaging probe in predicting the outcome of gastric peroral endoscopic pyloromyotomy (with video). Gastrointest Endosc 2020; 91:1289-1299. [PMID: 32035074 DOI: 10.1016/j.gie.2020.01.044] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 01/22/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Endoluminal functional luminal imaging probe (EndoFLIP) is an imaging tool that measures the physiologic characteristics of GI sphincters. In this study, we used EndoFLIP to evaluate the association between the pyloric physiologic measurements and the clinical outcomes of gastric peroral endoscopic myotomy (G-POEM) in patients with refractory gastroparesis. METHODS Thirty-seven patients from 5 centers who underwent G-POEM for management of refractory gastroparesis and had EndoFLIP measurements were evaluated. Cross-sectional area (CSA), balloon pressure, and the distensibility index (DI) of the pylorus were evaluated by EndoFLIP at 40 mL and 50 mL balloon fills before and after G-POEM. One-year clinical success and change in gastric emptying study 3 months after the G-POEM procedure were compared with the EndoFLIP measurements. RESULTS Clinical success was achieved in 26 (70%) patients. Post-G-POEM CSA and DI were significantly higher in the clinical success group with both 40-mL volume distension (CSA: 89.9 ± 64.8 vs 172.5 ± 71.9 mm2, P =.003; DI: 5.8 ± 4.4 vs 8.8 ± 6.1 mm2/mm Hg, P =.043) and 50-mL volume distention (CSA: 140.1 ± 89.9 vs 237.5 ± 80.3 mm2, P =.003; DI: 5.6 ± 3.3 vs 9.9 ± 6.6 mm2/mm Hg, P =.049). CSA using 40-mL volume distention with an area under the curve of 0.83 yielded a specificity of 91% and a sensitivity of 71% at a cutoff point of 154 mm2. CONCLUSIONS Post-G-POEM CSA of the pylorus is associated with clinical success and improvement in a gastric emptying scan after G-POEM. EndoFLIP measurements of the pylorus have the potential to be used as a tool to predict the clinical outcome of G-POEM.
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Affiliation(s)
- Kia Vosoughi
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Yervant Ichkhanian
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Jérémie Jacques
- Gastroenterology Department, Dupuytren University Hospital, Limoges, France
| | - A Aziz Aadam
- Division of Gastroenterology, Northwestern University, Chicago, Illinois, USA
| | - Petros C Benias
- Division of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, Northwell Health System, New Hyde Park, New York, USA
| | - Ryan Law
- Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan, USA
| | - William L Hasler
- Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan, USA
| | - Andrew Canakis
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Olivier Ragi
- Gastroenterology Department, Dupuytren University Hospital, Limoges, France
| | - Joseph Triggs
- Division of Gastroenterology, Northwestern University, Chicago, Illinois, USA
| | - Nicole Bowers
- Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Anthony N Kalloo
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Robert S Bulat
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - John E Pandolfino
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
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Abstract
Gastroparesis is characterized by delayed gastric emptying, with symptoms such as nausea, vomiting and abdominal pain, in the absence of mechanical obstruction. In most cases, it is idiopathic although diabetes mellitus is another leading cause. The physiology of gastric emptying is a complex process which is influenced by various inputs including the central nervous system, enteric nervous system and gut hormones. Developments in our understanding of gastroparesis have now demonstrated dysfunction in these systems, thus disrupting normal gastric emptying. Once mechanical obstruction is excluded, gastric scintigraphy remains the gold standard for diagnosis although wireless motility capsule and breath testing are alternative methods for diagnosis. Treatment for gastroparesis is challenging, and widely available therapies are often limited either by their poor evidence for efficacy or concerns over their long-term safety profile. Novel prokinetic agents have shown initial promise in clinical trials, and new endoscopic techniques such as gastric per-oral endoscopic myotomy are emerging. These new treatment modalities may provide an option in refractory gastroparesis with the adage of reduced morbidity compared to surgical treatments.
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Affiliation(s)
- A Sullivan
- Homerton University Hospital, London, UK
| | | | - A Ruban
- Department of Surgery and Cancer, Imperial College, London, UK.
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Peroral Pyloromytomy is Effective and Safe for Postsurgical Gastroparesis. J Gastrointest Surg 2020; 24:1417-1420. [PMID: 32166555 DOI: 10.1007/s11605-020-04558-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 02/24/2020] [Indexed: 01/31/2023]
Abstract
Gastric Per-oral Endoscopic pyloromyotomy (G-POEM) or per-oral pyloromyotomy (POP) is a novel procedure recently described for treatment of medically refractory gastroparesis; however, its efficacy and safety is not clear in patients with postsurgical gastroparesis (PsGP). We conducted a systematic review and meta-analysis to determine the efficacy and safety of G-POEM in PsGP. A total of 6 studies were included in the analysis. The pooled rate of success by gastroparesis cardinal symptom index (GCSI) and 4-h gastric emptying study (GES) were 89.6% (95% C.I. 72.7-96.5) and 81.5% (95% CI 47.8-95.5) respectively. There was a statistically significant improvement in GCSI score after 3 months of G-POEM as compared with pre G-POEM GCSI scores (2.7 (95% C.I. 0-5.5) vs 8.2 (95% C.I. 5.4-11) (p = 0.007). The mean pre G-POEM 4 h GES was 93.8% (95% C.I. 42.3-145.3) with improvement in post G-POEM GES to 44.5% (95% C.I. 0-95)(p = 0.2). The pooled rate of total adverse events was 9% (95% C.I. 2.7-25.9). Our study showed a good clinical success of G-POEM in PsGP patients along with significant improvement in 3-month GCSI scores. There was an improvement of GES after G-POEM, but it did not reach statistical significance. In conclusion, G-POEM is an effective and safe treatment option for PsGP.
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Bapaye A, Dubale NA. Gastric per-oral endoscopic myotomy: Indications, technique, outcomes, and future directions. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2020. [DOI: 10.18528/ijgii200014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Amol Bapaye
- Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, Pune, India
| | - Nachiket A. Dubale
- Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, Pune, India
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Liu AQ, Chiu PWY. Third space endoscopy: Current evidence and future development. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2020. [DOI: 10.18528/ijgii200007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Alex Qinyang Liu
- Division of Upper GI and Metabolic Surgery, Department of Surgery, Prince of Wales Hospital, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Philip Wai Yan Chiu
- Division of Upper GI and Metabolic Surgery, Department of Surgery, Prince of Wales Hospital, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
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Farha J, Fayad L, Kadhim A, Şimşek C, Badurdeen DS, Ichkhanian Y, Itani MI, Kalloo AN, Khashab MA, Kumbhari V. Gastric Per-Oral Endoscopic Myotomy (G-POEM) for the Treatment of Gastric Stenosis Post-Laparoscopic Sleeve Gastrectomy (LSG). Obes Surg 2020; 29:2350-2354. [PMID: 31001761 DOI: 10.1007/s11695-019-03893-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Laparoscopic sleeve gastrectomy (LSG) has become the most common form of bariatric surgery performed worldwide. However, it is associated with potentially debilitating adverse events such as post-operative stenosis. Finding effective and minimally invasive treatments for such complications is of paramount importance. Gastric per-oral endoscopic myotomy (G-POEM) is a novel procedure developed over the past decade to treat conditions that delay gastric emptying. We present a case demonstrating the use of G-POEM in the successful endoscopic management of post-LSG gastric stenosis.
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Affiliation(s)
- Jad Farha
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, 1800 Orleans St., Sheikh Zayed Tower, Suite 7125B, Baltimore, MD, 21287, USA
| | - Lea Fayad
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, 1800 Orleans St., Sheikh Zayed Tower, Suite 7125B, Baltimore, MD, 21287, USA
| | - Ali Kadhim
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, 1800 Orleans St., Sheikh Zayed Tower, Suite 7125B, Baltimore, MD, 21287, USA
| | - Cem Şimşek
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, 1800 Orleans St., Sheikh Zayed Tower, Suite 7125B, Baltimore, MD, 21287, USA
| | - Dilhana S Badurdeen
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, 1800 Orleans St., Sheikh Zayed Tower, Suite 7125B, Baltimore, MD, 21287, USA
| | - Yervant Ichkhanian
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, 1800 Orleans St., Sheikh Zayed Tower, Suite 7125B, Baltimore, MD, 21287, USA
| | - Mohamad I Itani
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, 1800 Orleans St., Sheikh Zayed Tower, Suite 7125B, Baltimore, MD, 21287, USA
| | - Anthony N Kalloo
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, 1800 Orleans St., Sheikh Zayed Tower, Suite 7125B, Baltimore, MD, 21287, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, 1800 Orleans St., Sheikh Zayed Tower, Suite 7125B, Baltimore, MD, 21287, USA
| | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, 1800 Orleans St., Sheikh Zayed Tower, Suite 7125B, Baltimore, MD, 21287, USA.
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Ichkhanian Y, Vosoughi K, Aghaie Meybodi M, Jacques J, Sethi A, Patel AA, Aadam AA, Triggs JR, Bapaye A, Dorwat S, Benias P, Chaves DM, Barret M, Law RJ, Browers N, Pioche M, Draganov PV, Kotzev A, Estremera F, Albeniz E, Ujiki MB, Callahan ZM, Itani MI, Brewer OG, Khashab MA. Comprehensive Analysis of Adverse Events Associated with Gastric Peroral Endoscopic Myotomy: An International Multicenter Study. Surg Endosc 2020; 35:1755-1764. [DOI: 10.1007/s00464-020-07570-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 04/15/2020] [Indexed: 02/08/2023]
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Spadaccini M, Maselli R, Chandrasekar VT, Anderloni A, Carrara S, Galtieri PA, Di Leo M, Fugazza A, Pellegatta G, Colombo M, Palma R, Hassan C, Sethi A, Khashab MA, Sharma P, Repici A. Gastric peroral endoscopic pyloromyotomy for refractory gastroparesis: a systematic review of early outcomes with pooled analysis. Gastrointest Endosc 2020; 91:746-752.e5. [PMID: 31809720 DOI: 10.1016/j.gie.2019.11.039] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 11/19/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Gastroparesis (GP) is a chronic debilitating condition. Prior pyloric-targeted procedures are either invasive or have questionable efficacy. Gastric peroral pyloromyotomy (G-POEM) has been proposed as a minimally invasive approach. We performed a pooled analysis to evaluate the efficacy and safety of G-POEM for GP. METHODS Electronic databases (Medline, Scopus, EMBASE) were searched up to January 2019. Studies including patients who underwent G-POEM for GP were eligible. Procedural, clinical, and safety outcomes were assessed by pooling data with a random- or fixed-effect model according to the degree of heterogeneity to obtain a proportion with a 95% confidence interval. RESULTS Ten studies were eligible for inclusion (292 patients), and 2 of the 10 studies were prospective. Seven studies were performed in the United States, 2 in France, and 1 in China. Endoscopic pyloromyotomy was feasible in all patients. Significant symptomatic improvement was achieved after 83.9% of procedures (mean follow-up, 7.8 ± 5.5 months). When comparing the mean values of pre- and postprocedural scintigraphic evolution, there was a significant decrease of the residual percentage at 2 and 4 hours. The overall adverse events rate was 6.8%. CONCLUSIONS G-POEM appears to be a promising approach for GP in terms of safety and efficacy outcomes in the short term.
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Affiliation(s)
- Marco Spadaccini
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center and Humanitas University, Rozzano, Italy
| | - Roberta Maselli
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center and Humanitas University, Rozzano, Italy
| | - Viveksandeep Thoguluva Chandrasekar
- Division of Gastroenterology and Hepatology, University of Kansas School of Medicine, Kansas City, Kansas, USA; Division of Gastroenterology and Hepatology, Veteran Affairs Medical Center, Kansas City, Missouri, USA
| | - Andrea Anderloni
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center and Humanitas University, Rozzano, Italy
| | - Silvia Carrara
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center and Humanitas University, Rozzano, Italy
| | - Piera Alessia Galtieri
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center and Humanitas University, Rozzano, Italy
| | - Milena Di Leo
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center and Humanitas University, Rozzano, Italy
| | - Alessandro Fugazza
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center and Humanitas University, Rozzano, Italy
| | - Gaia Pellegatta
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center and Humanitas University, Rozzano, Italy
| | - Matteo Colombo
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center and Humanitas University, Rozzano, Italy
| | - Rossella Palma
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center and Humanitas University, Rozzano, Italy
| | - Cesare Hassan
- Digestive Endoscopy Unit, Nuovo Regina Margherita Hospital, Rome, Italy
| | - Amrita Sethi
- Division of Gastroenterology and Hepatology, New York-Presbyterian Medical Center/Columbia University Medical Center, New York, New York, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Prateek Sharma
- Division of Gastroenterology and Hepatology, University of Kansas School of Medicine, Kansas City, Kansas, USA; Division of Gastroenterology and Hepatology, Veteran Affairs Medical Center, Kansas City, Missouri, USA
| | - Alessandro Repici
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center and Humanitas University, Rozzano, Italy
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Yan J, Tan Y, Zhou B, Zhang S, Wang X, Liu D. Gastric per-oral endoscopic myotomy (G-POEM) is a promising treatment for refractory gastroparesis: a systematic review and meta-analysis. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2020; 112:219-228. [PMID: 32081015 DOI: 10.17235/reed.2020.6559/2019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
AIM to evaluate the efficacy and safety of gastric per-oral endoscopic myotomy (G-POEM) for the treatment of refractory gastroparesis. METHODS PubMed, Embase and Cochrane databases were searched and used for study inclusion. Clinical studies since January 2013 to October 2019 were identified as suitable for inclusion. Conference papers, review articles, case reports, animal studies, letters, studies with repetitive data, studies that did not mention the Gastroparesis Cardinal Symptom Index (GCSI) score/gastric emptying scintigraphy (GES) hours or were not indicated in the standard form were excluded. GCSI score, GCSI reduction, gastric emptying scintigraphy at four hours (GES-4h) and GES time (GET) reduction were considered as major indexes and the meta-analysis was achieved using Review Manager 5.3. Research bias was measured according to Cochrane handbook. RESULTS nine studies were included with a total of 235 patients that underwent G-POEM, and the technical success rate was 100%. After G-POEM, patients reported changes in GCSI score (6/9 studies, mean difference 1.41 [CI: 0.93, 1.88], p < 0.0001), GCSI reduction (8/9 studies, odds ratio 3.00 [CI: 2.24, 4.03], p < 0.0001), GES-4h (8/9 studies, mean difference 23.78 [CI: 19.88, 27.68], p < 0.00001) and GET reduction (6/9 studies, odds ratio 3.50 [CI: 2.12, 5.78], p < 0.00001). The intra-procedure complication rate was 5.1% (12/235), including capnoperitoneum (seven cases) and accidental mucotomy (five cases). The post-procedure complication rate was 6.8% (16/235), including abdominal pain (three cases), bleeding (three cases), ulcer (one case), difficulty swallowing (one case) and others (eight cases). Both per- and post-procedure complications were easily managed by conservative or endoscopic treatments. CONCLUSION the results show that gastroparesis patients can benefit from G-POEM, the success rate was impressive and the complication rate was relatively low. However, caution is necessary when interpreting the results, primarily due to the limitations of uncontrolled studies. Randomized control studies are still needed for further evaluations.
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Affiliation(s)
- Jin Yan
- Gastroenterology, The Second Xiangya Hospital. Central South University, China
| | - Yuyong Tan
- Gastroenterology, The Second Xiangya Hospital. Central South University, China
| | - Bingyi Zhou
- Gastroenterology, The Second Xiangya Hospital. Central South University, China
| | - Shilan Zhang
- Gastroenterology, The Second Xiangya Hospital. Central South University, China
| | - Xuehong Wang
- Gastroenterology, The Second Xiangya Hospital. Central South University, China
| | - Deliang Liu
- Gastroenterology, The Second Xiangya Hospital. Central South University, China
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Issa D, Sampath K, Dawod Q, Azzam M, Sharaiha RZ, Carr-Locke D. Lesser curve approach to gastric peroral endoscopic myotomy: a case series. VideoGIE 2019; 4:532-534. [PMID: 31709350 PMCID: PMC6835000 DOI: 10.1016/j.vgie.2019.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
Background and Aims Methods Results Conclusion
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Wuestenberghs F, Juge M, Melchior C, Desprez C, Leroi AM, Gourcerol G. Association Between Symptoms, Quality of Life, and Gastric Emptying in Dyspeptic Patients. J Neurogastroenterol Motil 2019; 25:534-543. [PMID: 31587545 PMCID: PMC6786450 DOI: 10.5056/jnm19060] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 06/25/2019] [Accepted: 07/20/2019] [Indexed: 12/17/2022] Open
Abstract
Background/Aims Association between symptoms, quality of life and gastric emptying in dyspepsia is inconsistent in the literature. The aim of our study is to investigate if gastric emptying is associated with specific symptoms and quality of life in dyspeptic patients. Methods We reviewed retrospectively gastric emptying measured by 13C-labelled octanoate breath testing for more than 6 hours in 198 consecutive patients with dyspepsia complaints. Gastrointestinal symptoms were assessed using a 5-points Likert scale and by a symptomatic composite score, whereas quality of life was measured by the GIQLI. Results In our cohort, 90 patients (45%) had a delayed gastric emptying (half emptying time above 166 minutes when assessed over 6–8 hours). There was no difference in symptoms or quality of life between patients with or without delayed gastric emptying. However, patients with severely delayed gastric emptying (half emptying time above 200 minutes) had increased postprandial fullness (P = 0.012), abdominal pain (P = 0.026), bloating (P = 0.044), early satiety (P = 0.018), symptomatic composite score (P = 0.005), and a lower quality of life (P = 0.018). This association was no longer observed if the calculation of gastric emptying was limited to the first 4-hour samples. Conclusions There is no association between symptoms, quality of life and gastric emptying in an overall dyspeptic population. However, there is an association between symptoms, quality of life of delayed gastric emptying in the subgroup of patients with severely delayed gastric emptying. An 8-hour measurement of gastric emptying should be recommended.
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Affiliation(s)
- Fabien Wuestenberghs
- Department of Gastroenterology and Hepatology, CHU UCL Namur, Godinne University Hospital, UCLouvain, Yvoir, Belgium.,Department of Physiology, Rouen University Hospital, Normandie University, Rouen, France.,Nutrition, Gut and Brain Laboratory (INSERM UMR 1073), Institute for Biomedical Research and innovation, Rouen University, Normandie University, Rouen, France
| | - Mathilde Juge
- Department of Gastroenterology, Rouen University Hospital, Normandie University, Rouen, France
| | - Chloé Melchior
- Nutrition, Gut and Brain Laboratory (INSERM UMR 1073), Institute for Biomedical Research and innovation, Rouen University, Normandie University, Rouen, France.,Department of Gastroenterology, Rouen University Hospital, Normandie University, Rouen, France
| | - Charlotte Desprez
- Department of Physiology, Rouen University Hospital, Normandie University, Rouen, France
| | - Anne-Marie Leroi
- Department of Physiology, INSERM CIC-CRB 1404, Rouen University Hospital, INSERM Unit 1073, UNIROUEN, Normandie University, Rouen France
| | - Guillaume Gourcerol
- Department of Physiology, Rouen University Hospital, Normandie University, Rouen, France.,Nutrition, Gut and Brain Laboratory (INSERM UMR 1073), Institute for Biomedical Research and innovation, Rouen University, Normandie University, Rouen, France
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Clinical efficacy of gastric per-oral endoscopic myotomy (G-POEM) in the treatment of refractory gastroparesis and predictors of outcomes: a systematic review and meta-analysis using surgical pyloroplasty as a comparator group. Surg Endosc 2019; 34:3352-3367. [PMID: 31583465 DOI: 10.1007/s00464-019-07135-9] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 09/17/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND AIMS Gastric peroral endoscopic myotomy (G-POEM) is a novel minimally invasive technique in endosurgery. Data is limited as to its efficacy, safety, and predictive factors. We conducted this meta-analysis to evaluate the clinical outcomes of G-POEM and used the outcomes of surgical pyloroplasty as a comparator group in the treatment of refractory gastroparesis. METHODS We searched multiple databases from inception through March 2019 to identify studies that reported on G-POEM and pyloroplasty in gastroparesis. Our primary outcome was to analyze and compare the pooled rates of clinical success, in terms of Gastroparesis Cardinal Symptom Index (GCSI) score and 4-h gastric emptying study (GES) results, with G-POEM and pyloroplasty. RESULTS Three hundred and thirty-two and 375 patients underwent G-POEM (11 studies) and surgical pyloroplasty (seven studies), respectively. The pooled rate of clinical success, based on the GCSI score, with G-POEM was 75.8% (95% CI 68.1-82.1, I2 = 50) and with surgical pyloroplasty was 77.3% (95% CI 66.4-85.4, I2 = 0), with no significance, p = 0.81. The pooled rate of clinical success, based on the 4-hour GES results, with G-POEM was 85.1% (95% CI 68.9-93.7, I2 = 74) and with surgical pyloroplasty was 84% (95% CI 64.4-93.8, I2 = 81), with no significance, p = 0.91. The overall adverse events were comparable. Based on meta-regression analysis, idiopathic gastroparesis, prior treatment with botulinum toxin and gastric stimulator seemed to predict clinical success with G-POEM. CONCLUSION G-POEM demonstrates clinical success in treating refractory gastroparesis. Idiopathic gastroparesis, prior treatment with botulinum injections and gastric stimulator appear to have positive predictive effects on the 4-h GES results after G-POEM. Outcomes seem comparable to surgical pyloroplasty.
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Abstract
This review covers the epidemiology, pathophysiology, clinical features, diagnosis, and management of diabetic gastroparesis, and more broadly diabetic gastroenteropathy, which encompasses all the gastrointestinal manifestations of diabetes mellitus. Up to 50% of patients with type 1 and type 2 DM and suboptimal glycemic control have delayed gastric emptying (GE), which can be documented with scintigraphy, 13C breath tests, or a wireless motility capsule; the remainder have normal or rapid GE. Many patients with delayed GE are asymptomatic; others have dyspepsia (i.e., mild to moderate indigestion, with or without a mild delay in GE) or gastroparesis, which is a syndrome characterized by moderate to severe upper gastrointestinal symptoms and delayed GE that suggest, but are not accompanied by, gastric outlet obstruction. Gastroparesis can markedly impair quality of life, and up to 50% of patients have significant anxiety and/or depression. Often the distinction between dyspepsia and gastroparesis is based on clinical judgement rather than established criteria. Hyperglycemia, autonomic neuropathy, and enteric neuromuscular inflammation and injury are implicated in the pathogenesis of delayed GE. Alternatively, there are limited data to suggest that delayed GE may affect glycemic control. The management of diabetic gastroparesis is guided by the severity of symptoms, the magnitude of delayed GE, and the nutritional status. Initial options include dietary modifications, supplemental oral nutrition, and antiemetic and prokinetic medications. Patients with more severe symptoms may require a venting gastrostomy or jejunostomy and/or gastric electrical stimulation. Promising newer therapeutic approaches include ghrelin receptor agonists and selective 5-hydroxytryptamine receptor agonists.
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Affiliation(s)
- Adil E Bharucha
- Clinical Enteric Neuroscience Translational and Epidemiological Research Program, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Yogish C Kudva
- Division of Endocrinology. Mayo Clinic, Rochester, Minnesota
| | - David O Prichard
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
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Enhanced recovery outcomes following per-oral pyloromyotomy (POP): a comparison of safety and cost with same-day discharge versus inpatient recovery. Surg Endosc 2019; 34:3153-3162. [DOI: 10.1007/s00464-019-07085-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 08/21/2019] [Indexed: 12/16/2022]
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Rodriguez J, Strong AT, Haskins IN, Landreneau JP, Allemang MT, El-Hayek K, Villamere J, Tu C, Cline MS, Kroh M, Ponsky JL. Per-oral Pyloromyotomy (POP) for Medically Refractory Gastroparesis: Short Term Results From the First 100 Patients at a High Volume Center. Ann Surg 2019; 268:421-430. [PMID: 30004920 DOI: 10.1097/sla.0000000000002927] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE For patients with gastroparesis, temporary pyloric disruption has been shown to improve symptoms and gastric emptying. Per-oral pyloromyotomy (POP) is an innovative endoscopic procedure to divide the pylorus from within a submucosal tunnel, as a corollary to surgical pyloromyotomy. Here we evaluate subjective and objective outcomes 12-weeks after POP at a high volume center. METHODS The first 100 consecutive patients undergoing POP were included, with procedure dates between January 2016 and October 2017. Patients were evaluated using the Gastroparesis Cardinal Symptom Index (GCSI), and 4-hour solid-phase scintigraphic gastric emptying studies (GES) prior to procedure and at 90 days post-POP RESULTS:: The study cohort was 85% female with a mean age of 45.0 ± 14.6 years. Gastroparesis etiologies were divided among idiopathic (56%), diabetic (21%), postsurgical (19%), and other in 4%. There were 67% of the patients who had previous endoscopic or surgical interventions for gastroparesis. Most POP procedures were performed in the operating room (97%) and were completed in an average of 33 minutes. Ten patients incurred complications (10%), which included 1 diagnostic laparoscopy and 2 cases of gastrointestinal bleeding. Overall GCSI improved from a preoperative mean of 3.82 ± 0.86 to 2.54 ± 1.2 (P < 0.001). The improvement in each GCSI subscore was also highly statistically significant. Among the patients with postoperative GES available, 78% had objectively better 4-hour emptying with a mean improvement in retention by 23.6% (P < 0.001). This included 57% of patients with normal gastric emptying post-POP. CONCLUSION For patients with medically refractory gastroparesis, POP results in both subjective and objective improvement in the majority of patients. Prior intervention does not obviate POP as a therapeutic option. POP should be included along the treatment algorithm for patients with gastroparesis as an organ-sparing procedure.
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Affiliation(s)
- John Rodriguez
- Section of Surgical Endoscopy, Department of General Surgery Cleveland Clinic, Cleveland, OH.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
| | - Andrew T Strong
- Section of Surgical Endoscopy, Department of General Surgery Cleveland Clinic, Cleveland, OH.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
| | - Ivy N Haskins
- Department of General Surgery, George Washington University, Washington DC
| | - Joshua P Landreneau
- Section of Surgical Endoscopy, Department of General Surgery Cleveland Clinic, Cleveland, OH
| | - Matthew T Allemang
- Section of Surgical Endoscopy, Department of General Surgery Cleveland Clinic, Cleveland, OH
| | - Kevin El-Hayek
- Section of Surgical Endoscopy, Department of General Surgery Cleveland Clinic, Cleveland, OH.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH.,Section of Hepato-Pancreato-Biliary Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - James Villamere
- Section of Surgical Endoscopy, Department of General Surgery Cleveland Clinic, Cleveland, OH
| | - Chao Tu
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| | - Michael S Cline
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH.,Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Matthew Kroh
- Section of Surgical Endoscopy, Department of General Surgery Cleveland Clinic, Cleveland, OH.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH.,Digestive Disease Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Jeffrey L Ponsky
- Section of Surgical Endoscopy, Department of General Surgery Cleveland Clinic, Cleveland, OH.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
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Hedberg HM, Carbray J, Ujiki MB. Initial Experience with Endoscopic Pyloromyotomy, with Description and Video of Technique. J Gastrointest Surg 2019; 23:1706-1710. [PMID: 31062275 DOI: 10.1007/s11605-019-04237-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 04/20/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Gastric per oral endoscopic myotomy (G-POEM) is a recently developed incisionless procedure to address gastroparesis. It has been previously described to treat medical and postsurgical gastroparesis. The present study is a case series of patients undergoing G-POEM for a variety of indications, both elective and urgent. METHODS IRB approval was obtained for retrospective review of a prospectively collected database including patients who underwent G-POEM during a 1.5-year period. Using an upper endoscope, a mucosotomy is made 2 cm proximal to the pylorus on the anterior surface of the stomach. A submucosal tunnel is made to the pylorus muscle, which is completed incised. When possible, Endoflip® was used to evaluate pyloric distensibility before and after the myotomy. Patient demographic factors, additional procedures, and other follow-up were collected by chart review. Elective cases were offered repeat gastric emptying study at 6 months. RESULTS There were 17 patients available for review. The procedure was technically completed in all cases. There was one gastric perforation recognized on postoperative day two that was addressed with laparoscopy and omental patch. Median length of stay was zero days, and 13/17 (76%) of patients experienced symptomatic relief. Pyloric distensibility significantly decreased intraoperatively from 5.6 (± 1.7) to 10.8 (± 5.0) cm2/mmHg (p = 0.002). CONCLUSION This limited case series demonstrates G-POEM to be a versatile procedure able to address gastroparesis in a variety of settings. Success rates are congruent with previously published reports, and one serious complication was able to be addressed laparoscopically. Endoflip® was able to verify a successful myotomy intraoperatively. This procedure is an attractive alternative to less effective non-invasive treatments and a more invasive laparoscopic pyloroplasty.
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Affiliation(s)
- Herbert Mason Hedberg
- Department of Surgery, University of Chicago Medicine, 5841 S. Maryland Avenue, Chicago, IL, USA.
| | - JoAnn Carbray
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA
| | - Michael B Ujiki
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA
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Podboy A, Hwang JH. Technical review of gastric per-oral endoscopic myotomy. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2019. [DOI: 10.18528/ijgii190008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Alexander Podboy
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City, CA, USA
| | - Joo Ha Hwang
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City, CA, USA
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Letter to the Editor: "Gastric Per Oral Endoscopic Myotomy (G-POEM) for the Treatment of Refractory Gastroparesis: Early Experience". Dig Dis Sci 2019; 64:2054-2055. [PMID: 31098869 DOI: 10.1007/s10620-019-05669-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 05/08/2019] [Indexed: 02/05/2023]
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Podboy A, Hwang JH, Nguyen LA, Garcia P, Zikos TA, Kamal A, Triadafilopoulos G, Clarke JO. Gastric per-oral endoscopic myotomy: Current status and future directions. World J Gastroenterol 2019; 25:2581-2590. [PMID: 31210711 PMCID: PMC6558440 DOI: 10.3748/wjg.v25.i21.2581] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 04/25/2019] [Accepted: 04/29/2019] [Indexed: 02/06/2023] Open
Abstract
Gastroparesis, or symptomatic delayed gastric emptying in the absence of mechanical obstruction, is a challenging and increasingly identified syndrome. Medical options are limited and the only medication approved by the Food and Drug Administration for treatment of gastroparesis is metoclopramide, although other agents are frequently used off label. With this caveat, first-line treatments for gastroparesis include dietary modifications, antiemetics and promotility agents, although these therapies are limited by suboptimal efficacy and significant medication side effects. Treatment of patients that fail first-line treatments represents a significant therapeutic challenge. Recent advances in endoscopic techniques have led to the development of a promising novel endoscopic therapy for gastroparesis via endoscopic pyloromyotomy, also referred to as gastric per-oral endoscopic myotomy or per-oral endoscopic pyloromyotomy. The aim of this article is to review the technical aspects of the per-oral endoscopic myotomy procedure for the treatment of gastroparesis, provide an overview of the currently published literature, and outline potential next directions for the field.
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Affiliation(s)
- Alexander Podboy
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City, CA 94063, United States
| | - Joo Ha Hwang
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City, CA 94063, United States
| | - Linda A Nguyen
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City, CA 94063, United States
| | - Patricia Garcia
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City, CA 94063, United States
| | - Thomas A Zikos
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City, CA 94063, United States
| | - Afrin Kamal
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City, CA 94063, United States
| | - George Triadafilopoulos
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City, CA 94063, United States
| | - John O Clarke
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City, CA 94063, United States
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Abstract
OBJECTIVE. The purposes of this article are to familiarize radiologists with endoscopic techniques currently in use and to improve identification of clinically relevant imaging findings and procedural complications related to common endoscopic interventions. CONCLUSION. The frequency of performance of therapeutic endoscopic ultrasound-guided procedures has risen precipitously in the last decade. These procedures are replacing surgical and percutaneous approaches to a variety of disease entities. Recent advances include endoscopic bariatric procedures, endoscopic myotomies, and endoscopic ultrasound-guided drainage procedures.
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Gastric peroral endoscopic myotomy for gastroparesis: A systematic review of efficacy and safety. GASTROENTEROLOGIA Y HEPATOLOGIA 2019; 42:413-422. [PMID: 30954320 DOI: 10.1016/j.gastrohep.2019.01.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 01/17/2019] [Accepted: 01/29/2019] [Indexed: 02/07/2023]
Abstract
INTRODUCTION To assess the efficacy and safety of gastric peroral endoscopic myotomy for the treatment of gastroparesis. METHODS PubMed, Embase, Cochrane Library and Web of Science databases were searched from their earliest records to May 2018. The evaluation of clinical efficacy and safety was based on gastric emptying scintigraphy normalization, the improvement in clinical symptoms and adverse event rate. R 3.5.0 software was used to calculate the pooled estimate rates by meta-analysis. The improvement rate of the Gastroparesis Cardinal Symptom Index score was analyzed at different follow-up times. RESULTS Fourteen studies with a total of 276 patients were included in this systematic review. The pooled gastric emptying scintigraphy normalization rate was 61.3% (95% CI, 51.5-70.8%) and clinical symptom improvement rate was 88.2% (95% CI, 83.6-93.1%). Intra-operative complications were found in about 3.2% (95% CI, 0.1-4.2%) of all included patients, and postoperative adverse events in 2.1% (95% CI, 0.3-4.8%). The mean Gastroparesis Cardinal Symptom Index score improvement rate was about 90.2% at one month follow-up, 83.3% at three months, 70.3% at six months, 52.4% at twelve months and 57.1% at eighteen months. DISCUSSION Our systematic review demonstrates that gastric peroral endoscopic myotomy is a safe and effective treatment for gastroparesis. Though the short-term outcomes are promising, prospective, randomized, controlled studies with large sample size and long-term follow-up are required to further confirm these results.
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Abstract
With increasing survival after esophagectomy for cancer, a growing number of individuals living with the functional results of a surgically altered anatomy calls for attention to the effects of delayed gastric conduit emptying (DGCE) on health-related quality of life and nutritional impairment. We here give an overview of the currently available literature on DGCE, in terms of epidemiology, pathophysiology, diagnostics, prevention and treatment. Attention is given to controversies in the current literature and obstacles related to general applicability of study results, as well as knowledge gaps that may be the focus for future research initiatives. Finally, we propose that measures are taken to reach international expert agreement regarding diagnostic criteria and a symptom grading tool for DGCE, and that functional radiological methods are established for the diagnosis and severity grading of DGCE.
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Affiliation(s)
- Magnus Konradsson
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC) and Karolinska University Hospital, Stockholm, Sweden
| | - Magnus Nilsson
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC) and Karolinska University Hospital, Stockholm, Sweden
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Aghaie Meybodi M, Qumseya BJ, Shakoor D, Lobner K, Vosoughi K, Ichkhanian Y, Khashab MA. Efficacy and feasibility of G-POEM in management of patients with refractory gastroparesis: a systematic review and meta-analysis. Endosc Int Open 2019; 7:E322-E329. [PMID: 30842971 PMCID: PMC6400657 DOI: 10.1055/a-0812-1458] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 10/29/2018] [Indexed: 12/12/2022] Open
Abstract
Background and aim Clinical management of patients with gastroparesis is challenging. Prior pyloric targeted procedures are either invasive or have questionable long-term efficacy. Gastric per-oral endoscopic myotomy (G-POEM) has been recently introduced as a minimally invasive approach. In this review, we performed a meta-analysis to evaluate the feasibility and efficacy of this technique in the management of patients with refractory gastroparesis. Methods PubMed, Embase, and Scopus databases were searched to identify relevant studies published through May 2018. Weighted pool rates (WPR) of the clinical resolution were calculated. Pooled values of Gastroparesis Cardinal Symptom Index (GCSI) before and after the procedure were compared. Pooled difference in means comparing gastric emptying before and after the procedure was calculated. Fixed or random effect model was used according to the level of heterogeneity. Results Seven studies with 196 patients were included in the meta-analysis. The mean value of procedure duration was 69.7 (95 % confidence interval [95 % CI]: 39 - 99 minutes) and average estimate of hospital stay was 1.96 (95 % CI: 1.22 - 2.95) days. The WPR for clinical success was 82 % (95 % CI: 74 % - 87 %, I 2 = 0). Compared with pre-procedure GCSI values, mean values of GCSI were reduced significantly at 5 days (-1.57 (95 % CI:-2.2,-0.9), I 2 = 80 %) ( P < 0.001). Mean values of gastric emptying were significantly decreased 2 - 3 months after the procedure (-22.3 (95 %CI: -32.9, - 11.6), I 2 = 67 %) ( P < 0.05). Conclusion Due to the high rate of clinical success and low rate of adverse events, G-POEM should be considered in management of refractory gastroparesis.
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Affiliation(s)
| | - Bashar J. Qumseya
- Division of Gastroenterology and Hepatology, Archbold Medical Group/Florida State University, United States
| | - Delaram Shakoor
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, Maryland, United States
| | - Katie Lobner
- Welch Medical Library, Johns Hopkins University, Baltimore, Maryland, United States
| | - Kia Vosoughi
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, United States
| | - Yervant Ichkhanian
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, United States
| | - Mouen A. Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, United States
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Mekaroonkamol P, Shah R, Cai Q. Outcomes of per oral endoscopic pyloromyotomy in gastroparesis worldwide. World J Gastroenterol 2019; 25:909-922. [PMID: 30833798 PMCID: PMC6397720 DOI: 10.3748/wjg.v25.i8.909] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Revised: 01/10/2019] [Accepted: 01/26/2019] [Indexed: 02/06/2023] Open
Abstract
Per oral endoscopic pyloromyotomy (POP), also known as gastric per-oral endoscopic myotomy (GPOEM), is a novel procedure with promising potential for the treatment of gastroparesis. As more data emerge and the procedure is becoming more recognized in clinical practice, its safety and efficacy need to be carefully evaluated. Appropriate patient selection for favorable clinical success prediction after GPOEM also needs additional research. This review aims to systemically summarize the existing data on clinical outcomes of POP. Symptomatologic responses to the procedure, its adverse effects, procedural techniques, and predictive factors of clinical success are also discussed.
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Affiliation(s)
- Parit Mekaroonkamol
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA 30322, United States
| | - Rushikesh Shah
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA 30322, United States
| | - Qiang Cai
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA 30322, United States
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Liang GG, Zhang QK, Zhang GX, Liu MC. Therapeutic effect of a temporary transpyloric stent in refractory post-surgical gastroparesis: a case report. BMC Surg 2019; 19:27. [PMID: 30813940 PMCID: PMC6391776 DOI: 10.1186/s12893-019-0490-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Accepted: 02/19/2019] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Gastroparesis is a syndrome characterized by delayed gastric emptying with associated symptoms. It was reported that the symptoms of diabetic gastroparesis had been greatly improved by transpyloric stent placement. However, the use of stents in benign conditions is considered to be contraindicated because of the increasing risk of complications, such as stent migration, reflux, perforation, bleeding, and, most importantly, new strictures caused by stent-induced tissue hyperplasia. While temporary placement of a self-expanding metallic stent (SEMC) can drastically reduce the risk of complications, few reports are available on the treatment of refractory PSG by temporary transpyloric stent. Does it have a long-term clinical effect after the stent being retrieved? CASE PRESENTATION After accepting partial resection of the lesser curvature in another hospital, a patient developed refractory gastroparesis. The symptoms hadn't been improved after long-term drug therapy and balloon dilation therapy. Four months after surgery, a fully covered SEMC was placed by endoscopy in our hospital. Gastroparesis had been greatly improved. Two weeks later, the transpyloric stent was retrieved and the patient didn't show recurrent symptoms. Follow-ups were arranged at 3 months, 6 months and 1 year respectively, and there was no evidence of recurrence was found. CONCLUSIONS This case indicates that temporary transpyloric SEMC is a safe, effective and less invasive alternative for post-surgical gastroparesis patients.
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Affiliation(s)
- Guo-Gang Liang
- Department of General Surgery, the First Affiliated Hospital of Dalian Medical University, Dalian, 116011, Liaoning Province, China
| | - Qing-Kai Zhang
- Department of General Surgery, the First Affiliated Hospital of Dalian Medical University, Dalian, 116011, Liaoning Province, China
| | - Gui-Xin Zhang
- Department of General Surgery, the First Affiliated Hospital of Dalian Medical University, Dalian, 116011, Liaoning Province, China
| | - Mu-Cang Liu
- Department of General Surgery, the First Affiliated Hospital of Dalian Medical University, Dalian, 116011, Liaoning Province, China.
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Chang KJ. Endoscopic foregut surgery and interventions: The future is now. The state-of-the-art and my personal journey. World J Gastroenterol 2019; 25:1-41. [PMID: 30643356 PMCID: PMC6328959 DOI: 10.3748/wjg.v25.i1.1] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 12/13/2018] [Accepted: 12/14/2018] [Indexed: 02/06/2023] Open
Abstract
In this paper, I reviewed the emerging field of endoscopic surgery and present data supporting the contention that endoscopy can now be used to treat many foregut diseases that have been traditionally treated surgically. Within each topic, the content will progress as follows: "lessons learned", "technical considerations" and "future opportunities". Lessons learned will provide a brief background and update on the most current literature. Technical considerations will include my personal experience, including tips and tricks that I have learned over the years. Finally, future opportunities will address current unmet needs and potential new areas of development. The foregut is defined as "the upper part of the embryonic alimentary canal from which the pharynx, esophagus, lung, stomach, liver, pancreas, and part of the duodenum develop". Foregut surgery is well established in treating conditions such as gastroesophageal reflux disease (GERD), achalasia, esophageal diverticula, Barrett's esophagus (BE) and esophageal cancer, stomach cancer, gastric-outlet obstruction, and obesity. Over the past decade, remarkable progress in interventional endoscopy has culminated in the conceptualization and practice of endoscopic foregut surgery for various clinical conditions summarized in this paper. Regarding GERD, there are now several technologies available to effectively treat it and potentially eliminate symptoms, and the need for long-term treatment with proton pump inhibitors. For the first time, fundoplication can be performed without the need for open or laparoscopic surgery. Long-term data going out 5-10 years are now emerging showing extended durability. In respect to achalasia, per-oral endoscopic myotomy (POEM) which was developed in Japan, has become an alternative to the traditional Heller's myotomy. Recent meta-analysis show that POEM may have better results than Heller, but the issue of post-POEM GERD still needs to be addressed. There is now a resurgence of endoscopic treatment of Zenker's diverticula with improved technique (Z-POEM) and equipment; thus, patients are choosing flexible endoscopic treatment as opposed to open or rigid endoscopy options. In regard to BE, endoscopic submucosal dissection (ESD) which is well established in Asia, is now becoming more mainstream in the West for the treatment of BE with high grade dysplasia, as well as early esophageal cancer. In combination with all the ablation technologies (radiofrequency ablation, cryotherapy, hybrid argon plasma coagulation), the entire spectrum of Barrett's and related dysplasia and early cancer can be managed predominantly by endoscopy. Importantly, in regard to early gastric cancer and submucosal tumors (SMTs) of the stomach, ESD and full thickness resection (FTR) can excise these lesions en-bloc and endoscopic suturing is now used to close large defects and perforations. For treatment of patients with malignant gastric outlet obstruction (GOO), endoscopic gastro-jejunostomy is now showing better results than enteral stenting. G-POEM is also emerging as a treatment option for patients with gastroparesis. Obesity has become an epidemic in many western countries and is becoming also prevalent in Asia. Endoscopic sleeve gastroplasty (ESG) is now becoming an established treatment option, especially for obese patients with body mass index between 30 and 35. Data show an average weight loss of 16 kg after ESG with long-term data confirming sustainability. Finally, in respect to endo-hepatology, there are many new endoscopic interventions that have been developed for patients with liver disease. Endoscopic ultrasound (EUS)-guided liver biopsy and EUS-guided portal pressure measurement are exciting new frontiers for the endo-hepatologists.
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Affiliation(s)
- Kenneth J Chang
- H.H. Chao Comprehensive Digestive Disease Center, University of California, Irvine Medical Center, Orange, CA 92868, United States
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Outcomes and Future Directions of Per-Oral Endoscopic Pyloromyotomy: A View from France. Gastrointest Endosc Clin N Am 2019; 29:139-149. [PMID: 30396523 DOI: 10.1016/j.giec.2018.08.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Gastroparesis is a challenging functional gastroenterological disorder, the complex pathophysiology of which hampers development of therapeutic modalities. Per-oral pyloromyotomy (POP) is a promising endoscopic therapy with a short-term clinical success rate of greater than 80%. Interest in POP is increasing, particularly in France, a country in which there is considerable expertise in submucosal endoscopy and functional disorders. Long-term follow-up and pyloric function evaluation are needed to assess the efficacy of POP in gastroparetic patients.
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Bekkelund M, Sangnes DA, Gunnar Hatlebakk J, Aabakken L. Pathophysiology of idiopathic gastroparesis and implications for therapy. Scand J Gastroenterol 2019; 54:8-17. [PMID: 30638082 DOI: 10.1080/00365521.2018.1558280] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Idiopathic gastroparesis is a gastric motility disorder characterized by chronic upper gastrointestinal symptoms and delayed gastric emptying without an identifiable underlying condition. This review summarizes recent understanding of the pathophysiology and treatment of idiopathic gastroparesis. MATERIALS AND METHODS Structured literature search in the PubMed, Embase and ClinicalTrials.gov databases. RESULTS Idiopathic gastroparesis involves several alterations in gastric motility and sensation, including delayed gastric emptying, altered myoelectrical activity, impaired fundic accommodation, visceral hypersensitivity and disturbances in antropyloroduodenal motility and coordination. Multiple cellular changes have been identified, including depletion of interstitial cells of Cajal (ICC) and enteric nerves, as well as stromal fibrosis. The underlying cause of these changes is not fully understood but may be an immune imbalance, including loss of anti-inflammatory heme-oxygenase-1 positive (HO-1) macrophages. There is currently no causal therapy for idiopathic gastroparesis. The treatment ladder consists of dietary measures, prokinetic and antiemetic medications, and varying surgical or endoscopic interventions, including promising pyloric therapies. There are ongoing trials with several novel medications, raising hopes for future treatment. CONCLUSIONS Patients with idiopathic gastroparesis present several pathophysiological alterations in the stomach, where depletion of ICC is of special importance. Treatment is currently focused on alleviating symptoms through dietary adjustments, medication or surgical or endoscopic interventions.
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Affiliation(s)
- Mattis Bekkelund
- a Faculty of Medicine, Department of Clinical Medicine , University of Oslo , Oslo , Norway.,b Department of Medicine , National Centre for Functional Gastrointestinal Disorders, Haukeland University Hospital , Bergen , Norway
| | - Dag A Sangnes
- b Department of Medicine , National Centre for Functional Gastrointestinal Disorders, Haukeland University Hospital , Bergen , Norway.,c Department of Medicine , Haukeland University Hospital , Bergen , Norway.,d Clinical institute 1, University of Bergen , Bergen , Norway
| | - Jan Gunnar Hatlebakk
- b Department of Medicine , National Centre for Functional Gastrointestinal Disorders, Haukeland University Hospital , Bergen , Norway.,c Department of Medicine , Haukeland University Hospital , Bergen , Norway.,d Clinical institute 1, University of Bergen , Bergen , Norway
| | - Lars Aabakken
- a Faculty of Medicine, Department of Clinical Medicine , University of Oslo , Oslo , Norway.,e Department of Transplantation Medicine , Section for Gastroenterology, Oslo University Hospital , Oslo , Norway
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80
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Mekaroonkamol P, Dacha S, Patel V, Li B, Luo H, Shen S, Chen H, Cai Q. Outcomes of Per Oral Endoscopic Pyloromyotomy in the United States. Gastrointest Endosc Clin N Am 2019; 29:151-160. [PMID: 30396525 DOI: 10.1016/j.giec.2018.08.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Per oral endoscopic pyloromyotomy (POP) has emerged as an endoscopic intervention for refractory gastroparesis. Early experience in the United States showed exciting clinical response rate, reduced gastroparesis symptoms, improved quality of life, and decreased gastric-emptying time during midterm follow-up up to 18 months. One recent study also showed that the number of patient emergency room visits and hospitalizations decreased significantly after POP. The procedure is technically feasible and safe. As more data become available, it is important to identify patients who would benefit most from this novel procedure.
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Affiliation(s)
- Parit Mekaroonkamol
- Division of Digestive Diseases, Emory University School of Medicine, 615 Michael Street, Suite 201, Atlanta, GA 30322, USA
| | - Sunil Dacha
- Division of Digestive Diseases, Emory University School of Medicine, 615 Michael Street, Suite 201, Atlanta, GA 30322, USA
| | - Vaishali Patel
- Division of Digestive Diseases, Emory University School of Medicine, 615 Michael Street, Suite 201, Atlanta, GA 30322, USA
| | - Baiwen Li
- Division of Digestive Diseases, Emory University School of Medicine, 615 Michael Street, Suite 201, Atlanta, GA 30322, USA
| | - Hui Luo
- Division of Digestive Diseases, Emory University School of Medicine, 615 Michael Street, Suite 201, Atlanta, GA 30322, USA
| | - Shanshan Shen
- Division of Digestive Diseases, Emory University School of Medicine, 615 Michael Street, Suite 201, Atlanta, GA 30322, USA
| | - Huimin Chen
- Division of Digestive Diseases, Emory University School of Medicine, 615 Michael Street, Suite 201, Atlanta, GA 30322, USA
| | - Qiang Cai
- Division of Digestive Diseases, Emory University School of Medicine, 615 Michael Street, Suite 201, Atlanta, GA 30322, USA.
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81
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Gastric Emptying Scintigraphy Before Gastric per Oral Endoscopic Myotomy: Imaging May Inform Treatment. Gastrointest Endosc Clin N Am 2019; 29:127-137. [PMID: 30396522 DOI: 10.1016/j.giec.2018.08.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Gastric emptying scintigraphy (GES) helps to diagnose gastroparesis and is typically only used for whole stomach retention patterns. However, it may provide significantly more information when looking specifically at proximal and distal retention patterns. This article reviews global GES changes following gastric per oral endoscopic myotomy; how global, proximal, and distal GES measurements correlate to gastroparesis symptoms; and how proximal and distal GES may serve as proxies for the various mechanisms involved in gastroparesis. The authors' data on how GES may be used to select which patients will have success from G-POEM is also reviewed.
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82
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Khoury T, Mizrahi M, Mahamid M, Daher S, Nadella D, Hazou W, Benson A, Massarwa M, Sbeit W. State of the art review with literature summary on gastric peroral endoscopic pyloromyotomy for gastroparesis. J Gastroenterol Hepatol 2018; 33:1829-1833. [PMID: 29806114 DOI: 10.1111/jgh.14293] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 05/09/2018] [Accepted: 05/12/2018] [Indexed: 12/18/2022]
Abstract
Gastroparesis is a debilitating progressive disease that significantly impacts a patient's life with limited and challenging treatments available. Although the pathogenesis is multifactorial, pylorospasm is believed to have a major underlying role. Several therapeutic interventions directed to the pylorus have been developed over the last decade, including intra-pyloric injections of botulinum toxin, transpyloric stenting, and surgical pyloroplasty. All of these treatment options had limited and disappointing results. More recently, gastric peroral endoscopic myotomy (G-POEM) has been reported as a treatment for refractory gastroparesis. In this review article, we provide an overview on gastroparesis with a focus on the therapeutic interventions. In addition, we provide a literature summary and pool analysis of the clinical efficacy, scintigraphic efficacy, and safety profile of all studies that evaluated G-POEM in gastroparesis. Overall, seven studies have reported on the use of G-POEM in gastroparesis, and the pooled analysis of these studies showed a technical success of 100%, with clinical efficacy as assessed by the Gastroparesis Cardinal Symptoms Index of 81.5%, gastric emptying scintigraphy normalization in approximately 55.5% of the cases, perioperative complications in 7.6%, and intraoperative complications in 6.6%. This suggests that G-POEM is a new promising therapeutic intervention for the treatment of gastroparesis with durable effect and limited potential adverse events.
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Affiliation(s)
- Tawfik Khoury
- The Liver Unit, Institute of Gastroenterology and Liver Diseases, Hebrew University-Hadassah Medical Center, Jerusalem, Israel
| | - Meir Mizrahi
- Internal Medicine, Division of Gastroenterology, University of South Alabama College of Medicine, Mobile, Alabama, USA
| | - Mahmud Mahamid
- Gastroenterology and Endoscopy United, The Nazareth Hospital, EMMS, Nazareth, Israel
| | - Saleh Daher
- The Liver Unit, Institute of Gastroenterology and Liver Diseases, Hebrew University-Hadassah Medical Center, Jerusalem, Israel
| | - Divya Nadella
- Internal Medicine, Division of Gastroenterology, University of South Alabama College of Medicine, Mobile, Alabama, USA
| | - Wadi Hazou
- The Liver Unit, Institute of Gastroenterology and Liver Diseases, Hebrew University-Hadassah Medical Center, Jerusalem, Israel
| | - Ariel Benson
- The Liver Unit, Institute of Gastroenterology and Liver Diseases, Hebrew University-Hadassah Medical Center, Jerusalem, Israel
| | - Muhammad Massarwa
- The Liver Unit, Institute of Gastroenterology and Liver Diseases, Hebrew University-Hadassah Medical Center, Jerusalem, Israel
| | - Wisam Sbeit
- Bar Ilan Faculty of Medicine, Institute of Gastroenterology and Liver Diseases, Galilee Medical Center, Naharia, Israel
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83
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Camilleri M, Chedid V, Ford AC, Haruma K, Horowitz M, Jones KL, Low PA, Park SY, Parkman HP, Stanghellini V. Gastroparesis. Nat Rev Dis Primers 2018; 4:41. [PMID: 30385743 DOI: 10.1038/s41572-018-0038-z] [Citation(s) in RCA: 197] [Impact Index Per Article: 32.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Gastroparesis is a disorder characterized by delayed gastric emptying of solid food in the absence of a mechanical obstruction of the stomach, resulting in the cardinal symptoms of early satiety, postprandial fullness, nausea, vomiting, belching and bloating. Gastroparesis is now recognized as part of a broader spectrum of gastric neuromuscular dysfunction that includes impaired gastric accommodation. The overlap between upper gastrointestinal symptoms makes the distinction between gastroparesis and other disorders, such as functional dyspepsia, challenging. Thus, a confirmed diagnosis of gastroparesis requires measurement of delayed gastric emptying via an appropriate test, such as gastric scintigraphy or breath testing. Gastroparesis can have idiopathic, diabetic, iatrogenic, post-surgical or post-viral aetiologies. The management of gastroparesis involves: correcting fluid, electrolyte and nutritional deficiencies; identifying and treating the cause of delayed gastric emptying (for example, diabetes mellitus); and suppressing or eliminating symptoms with pharmacological agents as first-line therapies. Several novel pharmacologic agents and interventions are currently in the pipeline and show promise to help tailor individualized therapy for patients with gastroparesis.
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Affiliation(s)
- Michael Camilleri
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA.
| | - Victor Chedid
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Alexander C Ford
- Leeds Gastroenterology Institute, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds, UK
| | - Ken Haruma
- Department of Internal Medicine 2, General Medical Center, Kawasaki Medical School, Okayama, Japan
| | - Michael Horowitz
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Karen L Jones
- National Health and Medical Research Council of Australia Centre of Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, South Australia, Australia
| | - Phillip A Low
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Seon-Young Park
- Division of Gastroenterology, Chonnam National University School of Medicine, Gwangju, Republic of Korea
| | - Henry P Parkman
- GI Section, Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA
| | - Vincenzo Stanghellini
- Department of Digestive Diseases, Policlinico S. Orsola-Malpighi, University of Bologna, Bologna, Italy
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84
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Gastric Peroral Endoscopic Myotomy (G-POEM) as a Treatment for Refractory Gastroparesis: Long-Term Outcomes. Can J Gastroenterol Hepatol 2018; 2018:6409698. [PMID: 30425974 PMCID: PMC6217887 DOI: 10.1155/2018/6409698] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 08/26/2018] [Accepted: 09/27/2018] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND AND AIMS Gastric peroral endoscopic myotomy (G-POEM) has been regarded as a novel and minimally invasive therapy for refractory gastroparesis. This study reports the long-term outcomes and possible predictive factors for successful outcomes after G-POEM in an Asian population. METHODS This is a retrospective single-centre study of 16 patients who underwent G-POEM for refractory gastroparesis from August 2016 to October 2017. This study included 11 males and 5 females; in addition, 13 patients had postsurgical gastroparesis, and 3 patients had diabetes. The patients included had severe and refractory gastroparesis, as indicated by a Gastroparesis Cardinal Symptom Index (GCSI) score ≥20, and evidence of a delay on gastric emptying scintigraphy (GES). The primary outcome parameter was an assessment of the long-term clinical efficacy of the procedure. The secondary outcome parameter was the detection of possible predictive factors for success and the determination of cut-off values for such predictors. RESULTS Technical success was achieved in 100% of the patients, with a mean procedure time of 45.25±12.96 min. The long-term clinical response was assessed in all patients during a median follow-up of 14.5 months. Clinical success was achieved in 13 (81.25%) patients. There was a significant reduction in the GCSI scores and GES values after the procedure compared to the baseline values, with P values of <0.0001 and 0.012, respectively. Univariate regression analysis showed that the GCSI and GES had significant associations with the future clinical outcomes of the patients, but this finding was not confirmed in multivariate analysis. A GCSI cut-off score of ≤30 had a high sensitivity and a negative predictive value (NPV) of 100% for predicting a successful procedure. GES (half emptying time ≤221.6 min and 2-hour retention ≤78.6%) had a high specificity and a positive predictive value (PPV) of 100%. CONCLUSIONS G-POEM is a safe and effective treatment option with a long-term efficacy of 81.6%. GCSI and GES could serve as good predictive measures.
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85
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Abstract
PURPOSE OF REVIEW The purpose of this article is to review the recent literature and discuss the new approaches to the diagnosis and treatment of functional dyspepsia (FD). RECENT FINDINGS According to the recent American College of Gastroenterology (ACG) and Canadian Association of Gastroenterology (CAG) guideline for dyspepsia, Helicobacter pylori (H. pylori) eradication is recommended as a first treatment option, and proton pump inhibitors (PPIs), tricyclic antidepressants, and prokinetics are listed as second-line therapy. On the other hand, in the Japanese guideline for FD, PPIs and prokinetics are recommended as the first-line treatment. In Japan, acotiamide, a recently launched prokinetic, showed significant efficacy in several clinical trials performed either in Japan or Europe. Regarding non-pharmacological treatment, recent topics include acupuncture, electrical stimulation, gastric peroral endoscopic myotomy, and meal and lifestyle modification. These treatments have provided significant efficacy, which provides some insights into the main pathophysiology of this disease. Although FD is common among functional gastrointestinal disorders, it is not easy to relieve the dyspeptic symptoms of FD patients. Combinations of pharmacological and non-pharmacological treatment options are expected.
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86
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Affiliation(s)
- Allen A Lee
- Division of Gastroenterology, University of Michigan Health System, 3912 Taubman Center, 1500 E. Medical Center Dr., SPC 5362, Ann Arbor, MI, 48109, USA
| | - William L Hasler
- Division of Gastroenterology, University of Michigan Health System, 3912 Taubman Center, 1500 E. Medical Center Dr., SPC 5362, Ann Arbor, MI, 48109, USA.
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