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Eriksson SE, Gardner M, Sarici IS, Zheng P, Chaudhry N, Jobe BA, Ayazi S. Efficacy of Gastric-Stimulator as an Adjunct to Pyloroplasty for Gastroparesis: Characterizing Patients Suitable for Single Procedure versus Dual Procedure Approach. J Gastrointest Surg 2024:S1091-255X(24)00576-6. [PMID: 39127405 DOI: 10.1016/j.gassur.2024.08.007] [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: 05/12/2024] [Revised: 07/29/2024] [Accepted: 08/05/2024] [Indexed: 08/12/2024]
Abstract
BACKGROUND Pyloroplasty is an effective surgery for gastroparesis. However, some patients fail to improve after pyloric drainage and may require subsequent gastric electric stimulation. There is a paucity of data on the efficacy of gastric stimulator as an adjunct to failed pyloroplasty. This study aimed to describe our experience with pyloroplasty, determine the efficacy of gastric-stimulator for failed pyloroplasty, and compare the final outcomes of those who required pyloroplasty with and without gastric stimulator for gastroparesis. METHODS Records of patients who underwent primary pyloroplasty for gastroparesis at our institution were reviewed. Patients with poor symptomatic improvement after pyloroplasty underwent subsequent gastric-stimulator. Symptoms were assessed using the gastroparesis cardinal symptom index (GCSI) preoperatively and after each surgery. Severe gastroparesis was defined as GSCI total score ≥3. Outcomes were assessed after pyloroplasty in all patients and after stimulator in patients who failed pyloroplasty. Final outcomes were then compared between those who did and did not require adjunct gastric-stimulator. RESULTS The study population consisted of 104 patients (89.4% female) with a mean (SD) age of 42.2(11) and BMI of 26.9(7). Gastroparesis etiologies were 71.2% idiopathic, 17.3% diabetic, and 11.5% postsurgical. At 18.7(12) months after pyloroplasty there was a decrease in the GCSI total score [3.5(1) to 2.7(1.2), p=0.0012] and the rate of severe gastroparesis (71.9% to 29.3%, p<0.0001). Gastric emptying scintigraphy (GES) 4-hr retention decreased [36.5(24) to 15.3(18), p=0.0003]. Adjunct gastric-stimulator was required by 30 (28.8%) patients due to suboptimal outcomes with no improvement in GCSI (p=0.201) or GES (p=0.320). These patients were younger [40.5(10.6) vs 49.6(15.2), p=0.0016)], with higher baseline GSCI-Total scores [4.3(0.7)-vs-3.7(1.1), p<0.001] and more severe gastroparesis (100%-vs-55.6%, p<0.001). All other preoperative characteristics were similar. At 21.7(15) months after gastric-stimulator there was improvement in GCSI [4.1(0.7) to 2.6(1.1), p<0.0001], severe gastroparesis (100% to 33.3%, p<0.0001), and GES 4-hr retention [21.2(22) to 7.6(10), p=0.054]. Prior to gastric stimulator, those who failed pyloroplasty had significantly worse GCSI (p=0.0009) and GES (p=0.048). However, after gastric stimulator, GCSI and GES improved, and were comparable to those who only required pyloroplasty (p>0.05). CONCLUSION Pyloroplasty improved gastroparesis symptoms and gastric emptying, yet 28% failed, requiring gastric stimulator. Younger patients and those with preoperative GCSI scores ≥3 were more likely to fail. Gastric stimulator improved outcomes after failed pyloroplasty, with comparable final GCSI and GES to those who did not fail.
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Affiliation(s)
- Sven E Eriksson
- Foregut Division, Surgical Institute, Allegheny Health Network, Pittsburgh, PA; Chevalier Jackson Research Foundation, Esophageal Institute, Western Pennsylvania Hospital, Pittsburgh, PA
| | - Margaret Gardner
- Foregut Division, Surgical Institute, Allegheny Health Network, Pittsburgh, PA
| | - Inanc S Sarici
- Foregut Division, Surgical Institute, Allegheny Health Network, Pittsburgh, PA; Chevalier Jackson Research Foundation, Esophageal Institute, Western Pennsylvania Hospital, Pittsburgh, PA
| | - Ping Zheng
- Foregut Division, Surgical Institute, Allegheny Health Network, Pittsburgh, PA
| | - Naveed Chaudhry
- Foregut Division, Surgical Institute, Allegheny Health Network, Pittsburgh, PA
| | - Blair A Jobe
- Foregut Division, Surgical Institute, Allegheny Health Network, Pittsburgh, PA; Chevalier Jackson Research Foundation, Esophageal Institute, Western Pennsylvania Hospital, Pittsburgh, PA; Department of Surgery, Drexel University, Philadelphia, PA
| | - Shahin Ayazi
- Foregut Division, Surgical Institute, Allegheny Health Network, Pittsburgh, PA; Chevalier Jackson Research Foundation, Esophageal Institute, Western Pennsylvania Hospital, Pittsburgh, PA; Department of Surgery, Drexel University, Philadelphia, PA.
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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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Wierzbicka A, Ukleja A. Nutritional aspects in patients with gastroparesis. Curr Opin Gastroenterol 2024:00001574-990000000-00155. [PMID: 38935298 DOI: 10.1097/mog.0000000000001050] [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: 06/28/2024]
Abstract
PURPOSE OF THE REVIEW The purpose of this review was to highlight most recent updates on nutritional aspects in gastroparesis (GP) focusing on dietary recommendations, utilization of enteral and parenteral nutrition, endoscopic and surgical interventions. RECENT FINDINGS Recent data addressed eating patterns, nutritional interventions, and clarifications on the role of endoscopic and surgical interventions underlying an impact on nutritional management of GP patients. They support the importance of gastroparesis-specific diet in addition to drug therapy, and confirm the benefits of a modified low-fat, low-fiber diet. Current guidelines suggest a new approach to GP management based on predominant symptoms. Gastric peroral endoscopic pyloromyotomy (G-POEM) and surgical gastric electrical stimulator (GES) placement may be considered in individuals with nausea and vomiting before the need for jejunostomy tube placement for enteral feeding or parenteral nutrition. SUMMARY Current literature supports the importance of dietary interventions, focusing on low-fat and low-fiber diets, in addition to drug therapies. Severely fiber-restrictive diets may not be necessary. There is enhanced understanding when jejunal feeding should be incorporated for refractory cases with consideration of G-POEM or/and GES even before jejunal tube placement. This approach will require patient evaluation in specialized motility centers.
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Affiliation(s)
| | - Andrew Ukleja
- Department of Gastroenterology, Cleveland Clinic Florida, Weston, Florida, USA
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Zhang YX, Zhang YJ, Li M, Tian JX, Tong XL. Common Pathophysiological Mechanisms and Treatment of Diabetic Gastroparesis. J Neurogastroenterol Motil 2024; 30:143-155. [PMID: 38576367 PMCID: PMC10999838 DOI: 10.5056/jnm23100] [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: 07/06/2023] [Revised: 10/29/2023] [Accepted: 11/06/2023] [Indexed: 04/06/2024] Open
Abstract
Diabetic gastroparesis (DGP) is a common complication of diabetes mellitus, marked by gastrointestinal motility disorder, a delayed gastric emptying present in the absence of mechanical obstruction. Clinical manifestations include postprandial fullness and epigastric discomfort, bloating, nausea, and vomiting. DGP may significantly affect the quality of life and productivity of patients. Research on the relationship between gastrointestinal dynamics and DGP has received much attention because of the increasing prevalence of DGP. Gastrointestinal motility disorders are closely related to a variety of factors including the absence and destruction of interstitial cells of Cajal, abnormalities in the neuro-endocrine system and hormone levels. Therefore, this study will review recent literature on the mechanisms of DGP and gastrointestinal motility disorders as well as the development of prokinetic treatment of gastrointestinal motility disorders in order to give future research directions and identify treatment strategies for DGP.
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Affiliation(s)
- Yu-Xin Zhang
- Institute of Metabolic Diseases, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yan-Jiao Zhang
- Institute of Metabolic Diseases, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Min Li
- Institute of Metabolic Diseases, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Jia-Xing Tian
- Institute of Metabolic Diseases, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Xiao-Lin Tong
- Institute of Metabolic Diseases, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
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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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Drury AM, Albunni H, Al-Haddad M, Powelson JA, Lutz A, Fridell JA. Role of gastric peroral endoscopic myotomy (GPOEM) in chronic gastroparesis management after pancreas transplantation. Clin Transplant 2024; 38:e15176. [PMID: 37922244 DOI: 10.1111/ctr.15176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/11/2023] [Accepted: 10/20/2023] [Indexed: 11/05/2023]
Abstract
Gastroparesis is a common complaint among patients with diabetes. Symptoms tend to improve following successful pancreas transplantation (PTx), but persist despite euglycemia in a subset of patients. We aimed to assess the benefit of gastric peroral endoscopic myotomy (G-POEM) in persistent gastroparesis following PTx. This was a single center retrospective review of all patients who underwent G-POEM for persistent gastroparesis following PTx. Patient demographics, pre and post procedure perception of symptom severity according to the patient assessment of upper gastrointestinal symptoms severity index (PAGI-SYM), gastroparesis cardinal symptom index (GCSI) score, and 36-item short form survey (SF36) score along with gastric emptying scintigraphy (GES) were analyzed. Seven PTx recipients underwent G-POEM for persistent gastroparesis symptoms. The majority were female. All reported nausea/vomiting, abdominal pain, bloating, and post prandial fullness prior to G-POEM. The post procedure survey scores improved in all patients although this was not significant. The improvement in gastric emptying on GES was statistically significant. G-POEM is a relatively new treatment option for gastroparesis. While it requires specialized proceduralist and training, we have documented improvement in the management of symptoms. With increasing experience, we anticipate more significant benefit in post PTx patients with persistent symptoms of gastroparesis undergoing G-POEM.
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Affiliation(s)
- Allison M Drury
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Hashem Albunni
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Mohammad Al-Haddad
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - John A Powelson
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Andrew Lutz
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jonathan A Fridell
- Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
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7
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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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Li M, Gao N, Wang S, Guo Y, Liu Z. A global bibliometric and visualized analysis of the status and trends of gastroparesis research. Eur J Med Res 2023; 28:543. [PMID: 38017518 PMCID: PMC10683151 DOI: 10.1186/s40001-023-01537-1] [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: 11/26/2022] [Accepted: 11/17/2023] [Indexed: 11/30/2023] Open
Abstract
BACKGROUND Gastroparesis has a substantial impact on the quality of life but has limited treatment options, which makes it a public health concern. No bibliometric studies on gastroparesis have been published thus far. Thus, this article aims to summarize and analyze research hotspots to provide a reference for clinical researchers. MATERIALS AND METHODS Gastroparesis-related research articles were searched in the Web of Science Core Collection (WOSCC), and relevant information was extracted after screening. A total of 1033 documents were analyzed with the bibliometric method using Microsoft Excel, Citespace, and VOSviewer. RESULTS Overall, our search retrieved 1033 papers contributed by 966 research institutions from 53 countries. Since 1980, publications in this field have increased rapidly. United States (n = 645) and Temple University (n = 122) were the most productive country and institution, respectively. Parkman, with 96 publications, was the most prominent author. CONCLUSIONS Research hotspots in gastroparesis can be summarized into four domains: innovation in diagnostic modalities, change of oral therapeutic agents, choice of surgical interventions, and pathological mechanisms. Future research on gastroparesis should focus on the quality of life of patients, diagnostic techniques, pyloromyotomy, and transpyloric stent placement.
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Affiliation(s)
- Meng Li
- Department of Gastroenterology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, No. 5 Beixiange St., Xicheng District, Beijing, 100053, China
| | - Ning Gao
- Department of Acupuncture and Moxibustion, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, No. 5 Beixiange St., Xicheng District, Beijing, 100053, China
| | - Shaoli Wang
- Department of Gastroenterology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, No. 5 Beixiange St., Xicheng District, Beijing, 100053, China
| | - Yufeng Guo
- Department of Acupuncture and Moxibustion, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, No. 5 Beixiange St., Xicheng District, Beijing, 100053, China.
| | - Zhen Liu
- Department of Gastroenterology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, No. 5 Beixiange St., Xicheng District, Beijing, 100053, China.
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Tran D, Leeds SG, Fair L, Fang J, Rubarth C, McGowan T, Ramakrishnan S, Ogola G, Aladegbami B, Ward MA. Gastric per-oral endoscopic myotomy versus pyloric injection of botulinum toxin for the treatment of gastroparesis: our institutional experience and a systematic review of the literature. Surg Endosc 2023; 37:7280-7287. [PMID: 37430121 DOI: 10.1007/s00464-023-10262-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 06/27/2023] [Indexed: 07/12/2023]
Abstract
INTRODUCTION Gastric Per-Oral Endoscopic Myotomy (GPOEM) has been developed as an effective treatment option for patients with medically refractory gastroparesis. Other endoscopic options, such as pyloric injection of botulinum toxin (Botox), is often performed with limited efficacy. The purpose of this study was to evaluate GPOEM for the treatment of gastroparesis and compare its efficacy to Botox injection results reported in the literature. METHODS A retrospective review was conducted to identify all patients who underwent a GPOEM for the treatment of gastroparesis between September 2018 and June 2022. Changes in Gastric Emptying Scintigraphy (GES) studies and Gastroparesis Cardinal Symptom (GCSI) scores from the preoperative to postoperative period were analyzed. In addition, a systematic review was conducted to identify all publications reporting the outcomes of Botox injections for the treatment of gastroparesis. RESULTS A total of 65 patients (51 female, 14 male) underwent a GPOEM during the study period. Twenty-eight patients (22 female, 6 male) had both preoperative and postoperative GES studies in addition to GCSI scores. The etiologies of gastroparesis were diabetic (n = 4), idiopathic (n = 18), and postsurgical (n = 6). Fifty percent of these patients had undergone previous failed interventions including Botox injections (n = 6), gastric stimulator placement (n = 2), and endoscopic pyloric dilation (n = 6). Outcomes showed a significant decrease in GES percentages (mean difference = - 23.5%, p < 0.001) and GCSI scores (mean difference = - 9.6, p = 0.02) postoperatively. In the systematic review for Botox, transient mean improvements in postoperative GES percentages and GCSI scores were reported at 10.1% and 4.0, respectively. CONCLUSION GPOEM leads to significant improvement in GES percentages and GCSI scores postoperatively and is superior to Botox injection results reported in the literature.
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Affiliation(s)
- Daniel Tran
- Texas A&M College of Medicine, Bryan, TX, USA
| | - Steven G Leeds
- Department of Minimally Invasive Surgery, Baylor University Medical Center, 3417 Gaston Avenue, Suite 965, Dallas, TX, 75246, USA
- Center for Advanced Surgery, Baylor Scott and White Health, Dallas, TX, USA
- Texas A&M College of Medicine, Bryan, TX, USA
| | - Lucas Fair
- Department of Minimally Invasive Surgery, Baylor University Medical Center, 3417 Gaston Avenue, Suite 965, Dallas, TX, 75246, USA
- Center for Advanced Surgery, Baylor Scott and White Health, Dallas, TX, USA
- Research Institute, Baylor Scott and White Health, Dallas, TX, USA
| | - Jenifer Fang
- Center for Advanced Surgery, Baylor Scott and White Health, Dallas, TX, USA
| | - Charles Rubarth
- Research Institute, Baylor Scott and White Health, Dallas, TX, USA
| | - Titus McGowan
- Research Institute, Baylor Scott and White Health, Dallas, TX, USA
| | - Sudha Ramakrishnan
- Baylor Health Sciences Library, Baylor Scott and White Health, Dallas, TX, USA
| | - Gerald Ogola
- Research Institute, Baylor Scott and White Health, Dallas, TX, USA
| | - Bola Aladegbami
- Department of Minimally Invasive Surgery, Baylor University Medical Center, 3417 Gaston Avenue, Suite 965, Dallas, TX, 75246, USA
- Center for Advanced Surgery, Baylor Scott and White Health, Dallas, TX, USA
- Texas A&M College of Medicine, Bryan, TX, USA
| | - Marc A Ward
- Department of Minimally Invasive Surgery, Baylor University Medical Center, 3417 Gaston Avenue, Suite 965, Dallas, TX, 75246, USA.
- Center for Advanced Surgery, Baylor Scott and White Health, Dallas, TX, USA.
- Texas A&M College of Medicine, Bryan, TX, USA.
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Khashab MA, Wang AY, Cai Q. AGA Clinical Practice Update on Gastric Peroral Endoscopic Myotomy for Gastroparesis: Commentary. Gastroenterology 2023; 164:1329-1335.e1. [PMID: 37086247 DOI: 10.1053/j.gastro.2023.02.027] [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: 10/29/2022] [Revised: 02/11/2023] [Accepted: 02/18/2023] [Indexed: 04/23/2023]
Abstract
DESCRIPTION The purpose of this American Gastroenterological Association (AGA) Institute Clinical Practice Update (CPU) is to review the available evidence and provide expert advice regarding cognitive, procedural, and post-procedural aspects of performing gastric peroral endoscopic myotomy for the treatment of refractory gastroparesis. METHODS This CPU was commissioned and approved by the AGA Institute Clinical Practice Updates Committee (CPUC) and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership and underwent internal peer review by the CPUC and external peer review through standard procedures of Gastroenterology. This expert commentary incorporates important as well as recently published studies in this field, and it reflects the experiences of the authors who are advanced endoscopists with expertise in treating patients by performing third-space endoscopy and gastric peroral endoscopic myotomy.
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Affiliation(s)
- Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, Baltimore, Maryland
| | - Andrew Y Wang
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia.
| | - Qiang Cai
- Division of Gastroenterology and Hepatology, Louisiana State University Health Sciences at Shreveport, Shreveport, Louisiana
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11
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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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13
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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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Nabi Z, Reddy DN. Submucosal endoscopy: the present and future. Clin Endosc 2023; 56:23-37. [PMID: 36617645 PMCID: PMC9902679 DOI: 10.5946/ce.2022.139] [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: 04/26/2022] [Accepted: 07/22/2022] [Indexed: 01/10/2023] Open
Abstract
Submucosal endoscopy or third-space endoscopy utilizes the potential space between the mucosal and muscularis layers of the gastrointestinal tract to execute therapeutic interventions for various diseases. Over the last decade, endoscopic access to the submucosal space has revolutionized the field of therapeutic endoscopy. Submucosal endoscopy was originally used to perform endoscopic myotomy in patients with achalasia cardia, and its use has grown exponentially since. Currently, submucosal endoscopy is widely used to resect subepithelial tumors and to manage refractory gastroparesis and Zenker's diverticulum. While the utility of submucosal endoscopy has stood the test of time in esophageal motility disorders and subepithelial tumors, its durability remains to be established in conditions such as Zenker's diverticulum and refractory gastroparesis. Other emerging indications for submucosal endoscopy include esophageal epiphrenic diverticulum, Hirschsprung's disease, and esophageal strictures not amenable to conventional endoscopic treatment. The potential of submucosal endoscopy to provide easy and safe access to the mediastinum and peritoneal spaces may open doors to novel indications and rejuvenate the interest of endoscopists in natural orifice transluminal endoscopic surgery in the future. This review focuses on the current spectrum, recent updates, and future direction of submucosal endoscopy in the gastrointestinal tract.
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Affiliation(s)
- Zaheer Nabi
- Asian Institute of Gastroenterology, Hyderabad, India
| | - Duvvur Nageshwar Reddy
- Asian Institute of Gastroenterology, Hyderabad, India,Correspondence: Duvvur Nageshwar Reddy Asian Institute of Gastroenterology, 6-3-661 Somajiguda, Hyderabad 500 082, India E-mail:
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17
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Shimamura Y, Fujiyoshi Y, Fujiyoshi MRA, Inoue H. Evolving field of third-space endoscopy: Derivatives of peroral endoscopic myotomy. Dig Endosc 2023; 35:162-172. [PMID: 35816387 DOI: 10.1111/den.14400] [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: 07/05/2022] [Accepted: 07/07/2022] [Indexed: 01/24/2023]
Abstract
Third-space endoscopy, also known as submucosal endoscopy, allows for a wide range of therapeutic interventions within the submucosal layer and even into the muscular or subserosal layers of the gastrointestinal lumen. The technical development of peroral endoscopic myotomy (POEM) for achalasia has revolutionized the field of therapeutic endoscopy and the method has been continuously refined and modified. Although POEM has been applied to treat primary achalasia, it shows a favorable clinical response in other esophageal motility disorders and as a salvage treatment after previously failed intervention. Gastroesophageal reflux after POEM has drawn considerable attention and there have been major advancements in its prevention and management. POEM has led to advantageous derivatives such as peroral endoscopic tumor resection or submucosal tunneling endoscopic resection for resection of subepithelial lesions, Zenker POEM for hypopharyngeal diverticula, diverticular POEM for epiphrenic esophageal diverticula, and gastric POEM for refractory gastroparesis. These techniques have a similar concept, which constitutes submucosal tunneling with a mucosal flap valve and secure mucosal incision closure. The submucosal tunneling technique is widely accepted and continues to evolve. This study aimed to review in detail the indications, outcomes, and technical variations in POEM and explore several emerging submucosal tunneling procedures. This review will benefit future studies by providing a summary of recent developments in this field.
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Affiliation(s)
- Yuto Shimamura
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Yusuke Fujiyoshi
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | | | - Haruhiro Inoue
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
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18
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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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19
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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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20
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Soliman H, Oiknine E, Cohen-Sors B, Moszkowicz D, Gorbatchef C, Dior M, Nebunu N, Le Gall M, Coffin B, Duboc H. Efficacy and safety of endoscopic pyloric balloon dilation in patients with refractory gastroparesis. Surg Endosc 2022; 36:8012-8020. [PMID: 35437639 DOI: 10.1007/s00464-022-09230-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 03/29/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND AND AIMS There has been interest in the use of pyloric therapies for the treatment of refractory gastroparesis. However, data on endoscopic pyloric dilation are scarce. We aimed to assess the efficacy and safety of this procedure in refractory gastroparesis. METHODS We performed a retrospective analysis of 47 patients referred for refractory gastroparesis, confirmed by gastric emptying scintigraphy, and treated with endoscopic pyloric through-the-scope balloon dilation. The primary endpoint was the effectiveness of the procedure, evaluated with the Gastric Cardinal Symptom Index (GCSI) at 2 and 6 months. RESULTS A clinical response, defined by a 1.0 point decrease in the GCSI score, was observed in 25 patients at 2 months (53%) and in 19 patients at 6 months (40%). The mean GCSI score decreased significantly at 2 and 6 months compared to the preoperative score (3.9 ± 0.87 vs 2.3 ± 1.37 and 3.9 ± 0.87 vs 2.9 ± 1.27, respectively; p < 0.0001). No complication was observed. Nine patients had a delayed relapse at 1 year. A second dilation was performed for eight patients and it was effective in five of them (63%). The mean follow-up time of the patients was 27.0 ± 10.4 months. At 2 years, 15 patients still experienced improvement following this treatment (32%). No predictive factor of clinical response was identified. CONCLUSION The efficacy of pyloric dilation is 53% at 2 months, with sustained improvement in one third of patients at 2 years. This treatment should be considered as an alternative option to pyloromyotomy.
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Affiliation(s)
- Heithem Soliman
- Centre de Recherche Sur L'Inflammation, Université de Paris Cité, Inserm UMRS 1149, 75018, Paris, France.
- Hépato Gastro Entérologie, Hôpital Louis Mourier, DMU ESPRIT - GHU (AP-HP), 178 rue des Renouillers, 92700, Colombes, France.
| | - Elsa Oiknine
- Hépato Gastro Entérologie, Hôpital Louis Mourier, DMU ESPRIT - GHU (AP-HP), 178 rue des Renouillers, 92700, Colombes, France
| | - Boris Cohen-Sors
- Hépato Gastro Entérologie, Hôpital Louis Mourier, DMU ESPRIT - GHU (AP-HP), 178 rue des Renouillers, 92700, Colombes, France
| | - David Moszkowicz
- Service de Chirurgie Générale Et Digestive, AP-HP, Hôpital Louis Mourier, DMU ESPRIT-GHU AP-HP, Nord-Université de Paris, 92700, Colombes, France
| | - Caroline Gorbatchef
- Hépato Gastro Entérologie, Hôpital Louis Mourier, DMU ESPRIT - GHU (AP-HP), 178 rue des Renouillers, 92700, Colombes, France
| | - Marie Dior
- Hépato Gastro Entérologie, Hôpital Louis Mourier, DMU ESPRIT - GHU (AP-HP), 178 rue des Renouillers, 92700, Colombes, France
| | - Nicoleta Nebunu
- Hépato Gastro Entérologie, Hôpital Louis Mourier, DMU ESPRIT - GHU (AP-HP), 178 rue des Renouillers, 92700, Colombes, France
| | - Maude Le Gall
- Centre de Recherche Sur L'Inflammation, Université de Paris Cité, Inserm UMRS 1149, 75018, Paris, France
| | - Benoit Coffin
- Centre de Recherche Sur L'Inflammation, Université de Paris Cité, Inserm UMRS 1149, 75018, Paris, France
- Hépato Gastro Entérologie, Hôpital Louis Mourier, DMU ESPRIT - GHU (AP-HP), 178 rue des Renouillers, 92700, Colombes, France
| | - Henri Duboc
- Centre de Recherche Sur L'Inflammation, Université de Paris Cité, Inserm UMRS 1149, 75018, Paris, France
- Hépato Gastro Entérologie, Hôpital Louis Mourier, DMU ESPRIT - GHU (AP-HP), 178 rue des Renouillers, 92700, Colombes, 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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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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23
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Taft TH, Craven MR, Adler EP, Simons M, Nguyen L. Stigma experiences of patients living with gastroparesis. Neurogastroenterol Motil 2022; 34:e14223. [PMID: 34337831 DOI: 10.1111/nmo.14223] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 05/17/2021] [Accepted: 07/07/2021] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Stigmatization toward chronic digestive diseases is well documented. Patients perceive others hold negative stereotypes toward their disease and may internalize these beliefs as true. Because of this, stigmatization is associated with poor outcomes across disease-related and psychosocial domains. No study to date evaluates stigmatization toward patients living with gastroparesis (GP), a poorly understood disease affecting gastric motility. We aimed to gain deep understanding of stigma in patients living with gastroparesis. METHODS Patients with GP were recruited from two university-based gastroenterology practices as well as patient advocacy support groups. Participants underwent a semi-structured qualitative interview about their experiences with stigma related to their GP diagnosis, which were audio-recorded and transcribed to text for analysis using a grounded theory approach. Major themes with representative quotations were documented. RESULTS Twenty-three patients participated. The majority were White, female, with idiopathic GP under the care of a gastroenterologist. All patients reported stigma related to GP. Seven major themes were found: stigma from healthcare providers, stigma within interpersonal relationships, GP as an invisible disease, blame, unsolicited suggestions on how to manage disease, disclosure, and stigma resistance. CONCLUSIONS This is the first study to describe stigma experiences in patients with GP. The results suggest patients experience considerable stigmatization toward their condition from multiple sources. Patients also demonstrated resistance to negative beliefs, which can serve as a protective factor for the negative effects of disease stigma. Clinicians should be aware of stigma in GP patients, including their own potential internal biases and behaviors.
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Affiliation(s)
- Tiffany H Taft
- Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Meredith R Craven
- Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Emerald P Adler
- Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Division of Gastroenterology, Stanford University, Palo Alto, CA, USA
| | - Madison Simons
- Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Linda Nguyen
- Division of Gastroenterology, Stanford University, Palo Alto, CA, USA
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24
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Lee WD, Song JS, Kim BS, Yang MA, Lee YJ, Jung GM, Kim JW, Cho YK, Cho JW. Safety and efficacy of prophylactic gastric open peroral endoscopic myotomy for prevention of post-ESD stenosis: A case series (with video). J Dig Dis 2022; 23:220-227. [PMID: 35373499 DOI: 10.1111/1751-2980.13094] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 02/14/2022] [Accepted: 03/31/2022] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Endoscopic resection of over 3/4 of the lumen of the antrum or pylorus is a known risk factor for post-endoscopic submucosal dissection (ESD) stenosis. Local or systemic steroids may reduce the risk of stenosis, but their overall role in stenosis prevention remains controversial. We aimed to evaluate the efficacy and safety of prophylactic gastric open peroral endoscopic myotomy (GO-POEM) in preventing post-ESD stenosis. METHODS Ten patients who underwent GO-POEM during or immediately after ESD in the Presbyterian Medical Center between June 2017 and November 2020 were included. All patients underwent excision of over 3/4 of the lumen of the antrum or pylorus. GO-POEM was performed without submucosal tunneling. RESULTS Well-differentiated tubular adenocarcinoma, tubulovillous adenoma with high-grade dysplasia, and tubular adenoma with low-grade dysplasia were diagnosed in three, one, and six patients, respectively. GO-POEM was performed successfully in all the 10 patients. Stenosis could not be evaluated in one patient, whereas one of the remaining nine patients developed post-ESD stenosis. GO-POEM decreased the risk of post-ESD stenosis in the other eight patients. Two patients presented with intraprocedural bleeding, both of whom were managed endoscopically successfully. CONCLUSIONS Prophylactic GO-POEM may be a novel, effective and safe treatment modality for preventing post-ESD stenosis in the stomach. Well-designed, multicenter studies with large sample sizes are needed to confirm our results.
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Affiliation(s)
- Won Dong Lee
- Department of Internal Medicine, Presbyterian Medical Center, Jeonju, South Korea
| | - Jae Sun Song
- Department of Internal Medicine, Presbyterian Medical Center, Jeonju, South Korea
| | - Byung Sun Kim
- Department of Internal Medicine, Presbyterian Medical Center, Jeonju, South Korea
| | - Min A Yang
- Department of Internal Medicine, Presbyterian Medical Center, Jeonju, South Korea
| | - Young Jae Lee
- Department of Internal Medicine, Presbyterian Medical Center, Jeonju, South Korea
| | - Gum Mo Jung
- Department of Internal Medicine, Presbyterian Medical Center, Jeonju, South Korea
| | - Ji Woong Kim
- Department of Internal Medicine, Presbyterian Medical Center, Jeonju, South Korea
| | - Yong Keun Cho
- Department of Internal Medicine, Presbyterian Medical Center, Jeonju, South Korea
| | - Jin Woong Cho
- Department of Internal Medicine, Presbyterian Medical Center, Jeonju, South Korea
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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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Meling S, Bertoli D, Sangnes DA, Brock C, Drewes A, Ejskjaer N, Dimcevski G, Søfteland E. Diabetic Gastroenteropathy: Soothe the Symptoms or Unravel a Cure? Curr Diabetes Rev 2022; 18:e220321192412. [PMID: 34225633 DOI: 10.2174/1573399817666210322154618] [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: 11/16/2020] [Revised: 01/19/2021] [Accepted: 02/13/2021] [Indexed: 11/22/2022]
Abstract
Autonomic neuropathy in patients with diabetes mellitus, and especially complications related to gastrointestinal neuropathy, are often overlooked in the clinic. Diabetic gastroenteropathy affects every segment of the gastrointestinal tract and generates symptoms that may include nausea, early satiety, vomiting, abdominal pain, constipation, and diarrhea. Severe cases can be complicated by weight loss, dehydration, and electrolyte disturbances. The pathophysiology is complex, the diagnostics and treatment options are multidisciplinary, and there is generally a lack of evidence for the treatment options. The aims for this review are first to summarize the pathophysiology and describe possible and expected symptoms and complications.Further, we will try to supply the clinician with a straightforward tool for diagnostics, and then, we shall summarize established treatment options, including diet recommendations, pharmacological and non-pharmacological options. Finally, we will explore the multiple possibilities of novel treatment, looking at medications related to the pathophysiology of neuropathy, other manifestations of autonomic neuropathies, and symptomatic treatment for other gastrointestinal disorders, also including new knowledge of endosurgical and neuromodulatory treatment. The overall goal is to increase awareness and knowledge on this frequent diabetic complication and to provide better tools for diagnosis and treatment. Ultimately, we hope to encourage further research in this field, as there are clear shortcomings in terms of biomarkers, pathophysiology, as well as treatment possibilities. In conclusion, diagnosis and management of diabetic gastroenteropathy are challenging and often require multidisciplinary teams and multimodal therapies. Treatment options are sparse, but new pharmacological, endoscopic, and neuromodulatory techniques have shown promising results in initial studies.
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Affiliation(s)
- Sondre Meling
- Department of Medicine, Stavanger University Hospital, Stavanger, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Davide Bertoli
- Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Dag A Sangnes
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Christina Brock
- Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
- Steno Diabetes Center North Jutland, Aalborg, Denmark
| | - Asbjørn Drewes
- Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
- Steno Diabetes Center North Jutland, Aalborg, Denmark
| | - Niels Ejskjaer
- Steno Diabetes Center North Jutland, Aalborg, Denmark
- Department of Clinical Medicine and Endocrinology, Aalborg University Hospital, Aalborg, Denmark
| | - Georg Dimcevski
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Eirik Søfteland
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
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Kamal F, Khan MA, Lee-Smith W, Sharma S, Acharya A, Jowhar D, Farooq U, Aziz M, Kouanda A, Dai SC, Howden CW, Munroe CA. Systematic review with meta-analysis: one-year outcomes of gastric peroral endoscopic myotomy for refractory gastroparesis. Aliment Pharmacol Ther 2022; 55:168-177. [PMID: 34854102 DOI: 10.1111/apt.16725] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 10/05/2021] [Accepted: 11/22/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Several studies have examined the efficacy of gastric peroral endoscopic myotomy (G-POEM) for gastroparesis. AIM To evaluate the mid-term efficacy of G-POEM by meta-analysis of studies with a minimum 1 year of follow-up. METHODS We reviewed several databases from inception to 10 June 2021 to identify studies that evaluated the efficacy of G-POEM in refractory gastroparesis, and had at least 1 year of follow-up. Our outcomes of interest were clinical success at 1 year, adverse events, difference in mean pre- and 1 year post-procedure Gastroparesis Cardinal Symptom Index (GCSI) score, and difference in mean pre- and post-procedure EndoFLIP measurements. We analysed data using a random-effects model and assessed heterogeneity by I2 statistic. RESULTS We included 10 studies comprising 482 patients. Pooled rates (95% CI) of clinical success at 1 year and adverse events were 61% (49%, 71%) and 8% (6%, 11%), respectively. Mean GCSI at 1 year post-procedure was significantly lower than pre-procedure; mean difference (MD) (95% CI) -1.4 (-1.9, -0.9). Mean post-procedure distensibility index was significantly higher than pre-procedure in the clinical success group at 40 and 50 mL volume distension; standardised mean difference (95% CI) 0.82 (0.07, 1.64) and 0.91 (0.32, 1.49), respectively. In the clinical failure group, there was no significant difference between mean pre- and post-procedure EndoFLIP measurements. CONCLUSIONS G-POEM is associated with modest clinical success at 1 year. Additional studies with longer follow-up are required to evaluate its longer-term efficacy.
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Affiliation(s)
- Faisal Kamal
- Division of Gastroenterology, University of California-San Francisco, San Francisco, California, USA
| | - Muhammad Ali Khan
- Department of Gastroenterology, Hepatology and Nutrition, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Wade Lee-Smith
- Mulford Health Sciences Library, University of Toledo, Toledo, Ohio, USA
| | - Sachit Sharma
- Department of Medicine, University of Toledo, Toledo, Ohio, USA
- Division of Gastroenterology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Ashu Acharya
- Department of Medicine, University of Toledo, Toledo, Ohio, USA
| | - Dawit Jowhar
- Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Umer Farooq
- Department of Medicine, Loyola Medicine/MacNeal Hospital, Berwyn, Illinois, USA
| | - Muhammad Aziz
- Division of Gastroenterology, University of Toledo, Toledo, Ohio, USA
| | - Abdul Kouanda
- Division of Gastroenterology, University of California-San Francisco, San Francisco, California, USA
| | - Sun-Chuan Dai
- Division of Gastroenterology, University of California-San Francisco, San Francisco, California, USA
| | - Colin W Howden
- Division of Gastroenterology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Craig A Munroe
- Division of Gastroenterology, University of California-San Francisco, San Francisco, California, USA
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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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Ang TL, Bapaye A. Gastric per-oral endoscopic myotomy: Surely less invasive, but does it guarantee efficacy? J Gastroenterol Hepatol 2021; 36:2997-2998. [PMID: 34750865 DOI: 10.1111/jgh.15712] [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: 12/09/2022]
Affiliation(s)
- Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Duke-NUS Medical School, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Amol Bapaye
- Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, Erandwane, Pune, India
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Efficacy and safety of gastric peroral endoscopic myotomy (G-POEM) for refractory gastroparesis: 3-year follow up results. J Formos Med Assoc 2021; 121:1334-1341. [PMID: 34686412 DOI: 10.1016/j.jfma.2021.08.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 04/17/2021] [Accepted: 08/25/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND/PURPOSE Gastroparesis is a common but easily overlooked disease. Gastric peroral endoscopic myotomy (G-POEM) is one of the third-space endoscopy techniques to treat gastroparesis. In this study, we aimed to evaluate the efficacy and safety of G-POEM for patients with refractory gastroparesis. METHODS Between December 2017 and 2020, we consecutively enrolled patients with gastroparesis who failed after the administration of several kinds of medication and repeated admission for nutritional support. All patients underwent gastric emptying scintigraphy and answered a questionnaire on Gastroparesis Cardinal Symptom Index (GCSI). Demographic data, endoscopic procedure, and post procedural outcome were analyzed. RESULTS A total of 11 (9 women and 2 men) patients with refractory gastroparesis (nine with diabetes mellitus, one systemic lupus erythematosus, and one idiopathic) were enrolled. The mean (±standard deviation (SD)) procedure time was 61.82 (±18.99) min with technical and clinical success rates of 100% and 81.82%, respectively. A statistically significant improvement was observed in the clinical severity (mean GCSI score 36.00 vs. 14.73, p < 0.0001) and gastric emptying time (mean T1/2 341.92 vs. 65.92 min, p = 0.016) after G-POEM. Hospital stay was 7.18 (±4.49) days without mortality. Complications included 4 (36.36%) patients with self-limited postprocedural abdominal pain and 3 (27.27%) patients with intra-procedural pneumoperitoneum. During the mean follow-up period of 554.36 days, one (9.09%) patient had relapsed clinical symptoms after 6 months. CONCLUSIONS G-POEM is an efficient and safe pylorus-directed endoscopic therapy for refractory gastroparesis with promising results.
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Shiu SI, Shen SH, Luo HN. Short-term outcomes of different modalities of pyloromyotomy versus gastric electrical stimulation in the treatment of gastroparesis: A systemic review and meta-analysis. Medicine (Baltimore) 2021; 100:e27291. [PMID: 34664890 PMCID: PMC8448004 DOI: 10.1097/md.0000000000027291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 09/02/2021] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND The aim of this meta-analysis was to compare the short-term outcomes surrounding the efficacy and complication rate between different modalities of pyloromyotomy and gastric electrical stimulation (GES) in the treatment of gastroparesis. METHODS Comprehensive, computerized research was performed on PubMed, Embase, and the Cochrane Central Register of Controlled Trials. We additionally reviewed relevant articles, without any language limitations, published prior to April 15, 2020. Meta-analysis was conducted using RevMan 5.3 software. RESULTS Three studies totaling 196 participants who had received 4 interventions, including single per-oral pyloromyotomy (POP), double POP, laparoscopic pyloromyotomy, and GES, were eligible for analysis. Compared to single POP, double POP achieved a better clinical response with a pooled relative risk (RR) of 1.27 (95% confidence interval [CI], 1.01-1.60, P = .04), while laparoscopic pyloromyotomy and GES showed no difference with a pooled RR of 0.89 (95% CI, 0.74-1.08, P = .23) and 0.87 (95% CI, 0.73-1.04, P = .13), respectively. As for the recurrence and complication rates, only GES showed a borderline significance of recurrence in comparison to single POP (RR 2.17, 95% CI, 1.00-4.71, P = .05), while there were no differences in the remainder of the comparisons. CONCLUSIONS We conducted a detailed comparison of 3 modalities of pyloromyotomy and GES in the treatment of gastroparesis, with the results suggesting that double POP demonstrated better clinical success with similar recurrence and complication rates. In addition, GES may result in more recurrence amongst these interventions.
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Affiliation(s)
- Sz-Iuan Shiu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- Evidence-based Practice and Policymaking Committee, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Shih-Hsiung Shen
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Hua-Nong Luo
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
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August AT, Landisch R, Hassan M, Wall JK. Per Oral Pyloromyotomy for Treatment of Gastroparesis in a Pediatric Patient. JPGN REPORTS 2021; 2:e054. [PMID: 37207063 PMCID: PMC10191583 DOI: 10.1097/pg9.0000000000000054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 11/17/2020] [Indexed: 05/21/2023]
Affiliation(s)
- Auriel T. August
- From the Department of General Surgery, Stanford Hospital and Clinics, Stanford, CA
| | - Rachel Landisch
- the Division of Pediatric Surgery, Lucile Packard Children’s Hospital, Stanford, CA
| | - Maheen Hassan
- the Division of Pediatric Gastroenterology, Lucile Packard Children’s Hospital, Stanford, CA
| | - James K. Wall
- the Division of Pediatric Surgery, Lucile Packard Children’s Hospital, Stanford, CA
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Camilleri M. Relationship of motor mechanisms to gastroparesis symptoms: toward individualized treatment. Am J Physiol Gastrointest Liver Physiol 2021; 320:G558-G563. [PMID: 33566731 PMCID: PMC8238170 DOI: 10.1152/ajpgi.00006.2021] [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] [Indexed: 01/31/2023]
Abstract
Following a classical paper by Dr. Keith A. Kelly published in this journal, and over the past 40 years, there has been increased understanding of the functions of different regions of the stomach, specifically the fundus, antrum, and pylorus. Several of the important physiological principles were based on in vivo animal studies that led to the appreciation of regional function and control mechanisms. These include the roles of the extrinsic parasympathetic vagal innervation, the gastric enteric nervous system and electrical syncytium consisting of pacemaker cells and smooth muscle cells, and duodenogastric reflexes providing feedback regulation following the arrival of food and hydrogen ions stimulating the release of hormones and vagal afferent mechanisms that inhibit gastric motility and stimulate pyloric contractility. Further insights on the role of regional motor functions in gastric emptying were obtained from observations in patients following diverse gastric surgeries or bariatric procedures, including fundoplication, Billroth I and sleeve gastrectomy, and sleeve gastroplasty. Antropyloroduodenal manometry and measurements of pyloric diameter and distensibility index provided important assessments of the role of antral hypomotility and pylorospasm, and these constitute specific targets for individualized treatment of patients with gastroparesis. Moreover, in patients with upper gastrointestinal symptoms suggestive of gastroparesis, the availability of measurements of gastric accommodation and pharmacological agents to reduce gastric sensitivity or enhance gastric accommodation provide additional specific targets for individualized treatment. It is anticipated that, in the future, such physiological measurements will be applied in patients to optimize choice of therapy, possibly including identifying the best candidate for pyloric interventions.
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Affiliation(s)
- Michael Camilleri
- Division of Gastroenterology and Hepatology, Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Mayo Clinic, Rochester, Minnesota
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Mandavdhare HS, Mishra S, Kumar A, Shah J, Samanta J, Gupta P, Singh H, Dutta U. Per-oral Endoscopic Myotomy and Other Applications of Third Space Endoscopy: Current Status and Future Perspectives. Surg Laparosc Endosc Percutan Tech 2021; 31:624-636. [PMID: 33710101 DOI: 10.1097/sle.0000000000000920] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 01/13/2021] [Indexed: 11/27/2022]
Abstract
INTRODUCTION The modification of NOTES (natural orifice transluminal endoscopic surgery) by mucosal safety flap has introduced us to the world of third space endoscopy (TSE). POEM (per-oral endoscopic myotomy) for achalasia cardia being its first vista, the realm expanded so that we can now remove en bloc a subepithelial/intramural tumor by POET (per-oral endoscopic tumor resection), perform G-POEM (gastric per-oral endoscopic myotomy) for refractory gastroparesis, restore esophageal continuity in complete obstruction by performing POETRE (per-oral endoscopic tunneling for the restoration of the esophagus), divide the septum in Zenker diverticulum completely with negligible risk of perforation by Z-POEM (Zenker per-oral endoscopic myotomy) and relieve constipation in Hirschsprung disease by PREM (per-rectal endoscopic myotomy). However, the real potential of TSE became evident with the introduction of POEM with fundoplication. TSE has opened the gates of the peritoneal cavity. Improved expertise and equipment will make the role of endoscopist complimentary to the surgeon with the dawn of a new field in therapeutic endoscopy. AREAS COVERED This review intends to comprehensively discuss the various aspects of POEM for achalasia studied so far followed by a brief discussion about other applications of TSE and the future perspectives in this exciting field.
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Affiliation(s)
| | | | | | | | | | | | - Harjeet Singh
- Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Rangan V, Ukleja A. Gastroparesis in the Hospital Setting. Nutr Clin Pract 2020; 36:50-66. [PMID: 33336872 DOI: 10.1002/ncp.10611] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 11/04/2020] [Indexed: 12/15/2022] Open
Abstract
Gastroparesis (GP) is commonly seen in hospitalized patients. Refractory vomiting and related dehydration, electrolyte abnormalities, and malnutrition are indications for hospital admission. In addition, tube feeding intolerance is a common sign of gastric dysmotility in critically ill patients. The diagnosis and management of GP in the hospital setting can be quite challenging. Diagnostic tests are often deferred because of patient intolerance of the oral meal for standard scintigraphy or severity of the primary disease. The diagnosis of GP is often established on the basis of clinical scenario and risk factors for gastric motor dysfunction. Medical therapy in GP is directed toward controlling nausea and vomiting by prokinetic and antinausea medications and correcting nutrition risks or treating malnutrition with nutrition therapy. Enteral nutrition is the preferred nutrition intervention for patients with GP. Delayed gastric emptying in critically ill patients has a negative impact on the timely delivery of enteral feeding and meeting the energy and protein goals. Measures to improve gastric tolerance or provide feeding beyond the stomach are often needed, since early enteral nutrition has been an important target of therapy for critically ill patients. This review will address the current understanding of the mechanisms of GP and feeding intolerance in critical illness, diagnostic workup, drug therapies, and interventions to improve the provision of enteral nutrition in hospital settings when gastric dysmotility is present or suspected.
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Affiliation(s)
- Vikram Rangan
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Andrew Ukleja
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Watts LS, Baker JR, Lee AA, Harer K, Bowers N, Law R, Hasler WL. Impact of gastric per-oral endoscopic myotomy on static and dynamic pyloric function in gastroparesis patients. Neurogastroenterol Motil 2020; 32:e13892. [PMID: 32542920 DOI: 10.1111/nmo.13892] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 04/23/2020] [Accepted: 04/30/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Functional Lumen Imaging Probe (EndoFLIP) tests typically measure static pyloric parameters, but the pylorus exhibits phasic variations on manometry. Dynamic changes in pyloric function have not been quantified using EndoFLIP, and the impact of Gastric Per-Oral Endoscopic Myotomy (G-POEM) on static and dynamic pyloric activity in gastroparesis is unknown. METHODS EndoFLIP balloon inflation to 30, 40, and 50 mL was performed to measure mean, maximum, and minimum values and variability in pyloric diameter and distensibility before and after G-POEM in 20 patients with refractory gastroparesis. The impact of phasic contractions on these pyloric measures was compared. KEY RESULTS G-POEM increased mean (P < .0001) and maximum (P = .0002) pyloric diameters and mean (P = .02) and maximum (P = .02) pyloric distensibility on 50 mL EndoFLIP inflation but not intraballoon pressures or minimum diameters or distensibility. Temporal variability of pyloric diameter (P = .02) and distensibility (P = .02) also increased after G-POEM. Phasic coupled contractions propagating from the antrum through the pylorus were observed in 37.5% of recordings; other phasic activity including isolated pyloric contractions were seen in 23.3%. Variability of pyloric diameter and distensibility tended to be higher during recordings with phasic activity. Some pyloric responses to G-POEM were influenced by age, gastroparesis etiology, gastric emptying, and prior botulinum toxin injection. CONCLUSIONS & INFERENCES Pyloric activity exhibits dynamic changes on EndoFLIP testing in gastroparesis. G-POEM increases maximal but not minimal diameter and distensibility with increased variations, suggesting this therapy enhances pyloric opening but may not impair pyloric closure. Phasic pyloric contractions contribute to variations in pyloric activity.
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Affiliation(s)
- Lydia S Watts
- Division of Gastroenterology and Hepatology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Jason R Baker
- Division of Gastroenterology and Hepatology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Allen A Lee
- Division of Gastroenterology and Hepatology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Kimberly Harer
- Division of Gastroenterology and Hepatology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Nicole Bowers
- Division of Gastroenterology and Hepatology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Ryan Law
- Division of Gastroenterology and Hepatology, University of Michigan Health System, Ann Arbor, MI, USA
| | - William L Hasler
- Division of Gastroenterology and Hepatology, University of Michigan Health System, Ann Arbor, MI, USA
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37
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Marowski S, Xu Y, Greenberg JA, Funk LM, Lidor AO, Shada AL. Both gastric electrical stimulation and pyloric surgery offer long-term symptom improvement in patients with gastroparesis. Surg Endosc 2020; 35:4794-4804. [DOI: 10.1007/s00464-020-07960-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 08/27/2020] [Indexed: 02/07/2023]
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Kantsevoy SV, Curtin BF. Double pyloromyotomy shows promise in gastric peroral endoscopic myotomy, but important questions remain. Gastrointest Endosc 2020; 92:610-612. [PMID: 32838909 DOI: 10.1016/j.gie.2020.05.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 05/26/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Sergey V Kantsevoy
- Institute for Digestive Health and Liver Diseases, Mercy Medical Center, Baltimore, Maryland, USA; University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Bryan F Curtin
- Institute for Digestive Health and Liver Diseases, Mercy Medical Center, Baltimore, Maryland, USA
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Kim D. The Optimal Pyloric Procedure: A Collective Review. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2020; 53:233-241. [PMID: 32793458 PMCID: PMC7409877 DOI: 10.5090/kjtcs.2020.53.4.233] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 06/02/2020] [Accepted: 06/10/2020] [Indexed: 01/04/2023]
Abstract
Vagal damage and subsequent pyloric denervation inevitably occur during esophagectomy, potentially leading to delayed gastric emptying (DGE). The choice of an optimal pyloric procedure to overcome DGE is important, as such procedures can lead to prolonged surgery, shortening of the conduit, disruption of the blood supply, and gastric dumping/bile reflux. This study investigated various pyloric methods and analyzed comparative studies in order to determine the optimal pyloric procedure. Surgical procedures for the pylorus include pyloromyotomy, pyloroplasty, or digital fracture. Botulinum toxin injection, endoscopic balloon dilatation, and erythromycin are non-surgical procedures. The scope, technique, and effects of these procedures are changing due to advances in minimally invasive surgery and postoperative interventions. Some comparative studies have shown that pyloric procedures are helpful for DGE, while others have argued that it is difficult to reach an objective conclusion because of the variety of definitions of DGE and evaluation methods. In conclusion, recent advances in interventional technology and minimally invasive surgery have led to questions regarding the practice of pyloric procedures. However, many clinicians still perform them and they are at least somewhat effective. To provide guidance on the optimal pyloric procedure, DGE should first be defined clearly, and a large-scale study with an objective evaluation method will then be required.
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Affiliation(s)
- Dohun Kim
- Department of Thoracic and Cardiovascular Surgery, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea
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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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Usai-Satta P, Bellini M, Morelli O, Geri F, Lai M, Bassotti G. Gastroparesis: New insights into an old disease. World J Gastroenterol 2020. [DOI: 10.3748/wjg.v26.i19.2332] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/24/2023] Open
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Usai-Satta P, Bellini M, Morelli O, Geri F, Lai M, Bassotti G. Gastroparesis: New insights into an old disease. World J Gastroenterol 2020; 26:2333-2348. [PMID: 32476797 PMCID: PMC7243643 DOI: 10.3748/wjg.v26.i19.2333] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 03/08/2020] [Accepted: 04/30/2020] [Indexed: 02/06/2023] Open
Abstract
Gastroparesis (Gp) is a chronic disease characterized by a delayed gastric emptying in the absence of mechanical obstruction. Although this condition has been reported in the literature since the mid-1900s, only recently has there been renewed clinical and scientific interest in this disease, which has a potentially great impact on the quality of life. The aim of this review is to explore the pathophysiological, diagnostic and therapeutical aspects of Gp according to the most recent evidence. A comprehensive online search for Gp was carried out using MEDLINE and EMBASE. Gp is the result of neuromuscular abnormalities of the gastric motor function. There is evidence that patients with idiopathic and diabetic Gp may display a reduction in nitrergic inhibitory neurons and in interstitial cells of Cajal and/or telocytes. As regards diagnostic approach, 99-Technetium scintigraphy is currently considered to be the gold standard for Gp. Its limits are a lack of standardization and a mild risk of radiation exposure. The C13 breath testing is a valid and safe alternative method. 13C acid octanoic and the 13C Spirulina platensis recently approved by the Food and Drug Administration are the most commonly used diagnostic kits. The wireless motility capsule is a promising technique, but its use is limited by costs and scarce availability in many countries. Finally, therapeutic strategies are related to the clinical severity of Gp. In mild and moderate Gp, dietary modification and prokinetic agents are generally sufficient. Metoclopramide is the only drug approved by the Food and Drug Administration for Gp. However, other older and new prokinetics and antiemetics can be considered. As a second-line therapy, tricyclic antidepressants and cannabinoids have been proposed. In severe cases the normal nutritional approach can be compromised and artificial nutrition may be needed. In drug-unresponsive Gp patients some alternative strategies (endoscopic, electric stimulation or surgery) are available.
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Affiliation(s)
- Paolo Usai-Satta
- Department of Internal Medicine, Division of Gastroenterology, Brotzu Hospital, Cagliari 09124, Italy
| | - Massimo Bellini
- Gastrointestinal Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa 56122, Italy
| | - Olivia Morelli
- Gastroenterology and Hepatology Section, Department of Medicine, University of Perugia Medical School, Perugia 06123, Italy
| | - Francesca Geri
- Gastrointestinal Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa 56122, Italy
| | - Mariantonia Lai
- Gastroenterology Unit, University of Cagliari, Monserrato 09042, Italy
| | - Gabrio Bassotti
- Gastroenterology and Hepatology Section, Department of Medicine, University of Perugia Medical School, Perugia 06123, Italy
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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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