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Gonzalez JM, Mion F, Pioche M, Garbay V, Baumstarck K, Boucekine M, Debourdeau A, Rivory J, Barthet M, Vitton V. Gastric peroral endoscopic myotomy versus botulinum toxin injection for the treatment of refractory gastroparesis: results of a double-blind randomized controlled study. Endoscopy 2024; 56:345-352. [PMID: 38141620 DOI: 10.1055/a-2235-3286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2023]
Abstract
INTRODUCTION Gastric peroral endoscopic myotomy (G-POEM) is a promising technique for treating refractory gastroparesis. We present the first double-blind randomized study comparing the clinical efficacy of G-POEM versus pyloric botulinum toxin injection (BTI). METHODS This randomized study, conducted in two expert centers, enrolled patients with refractory gastroparesis, medically managed for >6 months and confirmed by gastric emptying scintigraphy (GES), into two groups, G-POEM versus BTI, with follow-up of 1 year. The primary end point was the 3-month clinical efficacy, defined as a >1-point decrease in the mean Gastroparesis Cardinal Symptom Index (GCSI) score. Secondary end points were: 1-year efficacy, GES evolution, adverse events, and quality of life. RESULTS 40 patients (22 women; mean age 48.1 [SD 17.4]), with mean symptom duration of 5.8 (SD 5.7) years, were randomized. Etiologies included idiopathic (n=18), diabetes (n=11), postoperative (n=6), and mixed (n=4). G-POEM showed a higher 3-month clinical success than BTI (65% vs. 40%, respectively; P=0.10), along with non-significantly higher 1-year clinical success (60% vs. 40%, respectively) on intention-to-treat analysis. The GCSI decreased in both groups at 3 months and 1 year. Only three minor adverse events occurred in the G-POEM group. The GES improvement rate was 72% in the G-POEM group versus 50% in the BTI group (non-significant). CONCLUSION G-POEM seems to have a higher clinically relevant success rate than BTI, but this was not statistically demonstrated. This study confirms the interest in treatments targeting the pylorus, either mechanically or chemically, for managing refractory gastroparesis.
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Affiliation(s)
| | | | - Mathieu Pioche
- Endoscopy Unit, Digestive Disease Department, Hôpital Edouard Herriot, Lyon, France
| | - Victor Garbay
- Hôpital Nord, Gastroenterology, AP-HM, Marseille, France
| | - Karine Baumstarck
- Public Health, Aix-Marseille Université Faculté de Medecine, Marseille, France
| | - Mohamed Boucekine
- Public Health, Aix-Marseille Université Faculté de Medecine, Marseille, France
| | | | - Jérôme Rivory
- Endoscopy Unit, Digestive Disease Department, Hôpital Edouard Herriot, Lyon, France
| | - Marc Barthet
- Hôpital Nord, Gastroenterology, AP-HM, Marseille, France
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Fan Z, Qiu Y, Qi X, Xu J, Wan Y, Hao Y, Niu W, Huang J. Invasive acupuncture for gastroparesis after thoracic or abdominal surgery: a systematic review and meta-analysis. BMJ Open 2023; 13:e068559. [PMID: 37369406 PMCID: PMC10410841 DOI: 10.1136/bmjopen-2022-068559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 05/26/2023] [Indexed: 06/29/2023] Open
Abstract
OBJECTIVES This meta-analysis aimed to systematically evaluate the efficacy of acupuncture in treating postsurgical gastroparesis syndrome (PGS) after thoracic or abdominal surgery. DESIGN Systematic review and meta-analysis. DATA SOURCES Twelve databases (PubMed, Embase, Cochrane Library Cochrane Central Register of Controlled Trials (CENTRAL), Medline (Ovid) (from 1946), Web of Science, EBSCO, Scopus, Open Grey, China National Knowledge Infrastructure (CNKI), Wanfang Database, Chinese Scientific Journals Database (VIP) and China Biology Medicine disc (CBM)) and three registration websites (WHO International Clinical Trials Registry Platform (ICTRP), ClinicalTrials.gov, and Chinese Clinical Trial Registry (ChiCTR)) were searched from the inception to September 2022, and citations of the included literature were screened. ELIGIBILITY CRITERIA All randomised controlled trials addressing invasive acupuncture for PGS. DATA EXTRACTION AND SYNTHESIS Key information on the included studies was extracted by two reviewers independently. Risk ratio (RR) with 95% CI was used for categorical data, and mean difference with 95% CI for continuous data. The quality of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation. Outcomes were conducted with trial sequential analysis (TSA). RESULTS Fifteen studies with 759 patients met the inclusion criteria. Subgroup analyses revealed that compared with the drug group, the drug and acupuncture group had a greater positive effect on the total effective rate (TER) (nine trials, n=427; RR=1.20; 95% CI 1.08 to 1.32; P-heterogeneity=0.20, I2=28%, p=0.0004) and the recovery rate (RCR) (six trials, n = 294; RR = 1.61; 95% CI 1.30 to 1.98; P-heterogeneity=0.29, I2=19%, p<0.0001) of PGS after abdominal surgery. However, acupuncture showed no significant advantages in terms of the TER after thoracic surgery (one trial, p=0.13) or thoracic/abdominal surgery-related PGS (two trials, n = 115; RR=1.18; 95% CI 0.89 to 1.57; P-heterogeneity=0.08, I2=67%, p=0.24) and the RCR after thoracic/abdominal surgery (two trials, n=115; RR=1.40; 95% CI 0.97 to 2.01; P-heterogeneity=0.96, I2=0%, p=0.07). The quality of evidence for TER and RCR was moderate certainty. Only one study reported an acupuncture-related adverse event, in the form of mild local subcutaneous haemorrhage and pain that recovered spontaneously. TSA indicated that outcomes reached a necessary effect size except for clinical symptom score. CONCLUSION Based on subgroup analysis, compared with the drug treatment, acupuncture combined drug has significant advantages in the treatment of PGS associated with abdominal surgery, but not with thoracic surgery. PROSPERO REGISTRATION NUMBER CRD42022299189.
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Affiliation(s)
- Zhenjia Fan
- Department of minimally invasive acupuncture Oncology, Third Affiliated Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Yuqin Qiu
- Department of Integrated Traditional Chinese and Western Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xuewei Qi
- Department of minimally invasive acupuncture Oncology, Third Affiliated Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Jingnan Xu
- Department of minimally invasive acupuncture Oncology, Third Affiliated Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Yuxiang Wan
- Department of minimally invasive acupuncture Oncology, Third Affiliated Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Yingxu Hao
- Oncology Department of Integrated Traditional Chinese and Western Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Wenquan Niu
- Center for Evidence-Based Medicine, Capital Institute of Pediatrics, Beijing, China
| | - Jinchang Huang
- Department of minimally invasive acupuncture Oncology, Third Affiliated Hospital, Beijing University of Chinese Medicine, Beijing, China
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Testoni PA. Transorifice endoscopic myotomy for treating motility disorders of the gastrointestinal tract: state of the art and future perspectives. Minerva Gastroenterol (Torino) 2023; 69:171-174. [PMID: 37191669 DOI: 10.23736/s2724-5985.21.03073-4] [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: 05/17/2023]
Affiliation(s)
- Pier A Testoni
- Division of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Milan, Italy -
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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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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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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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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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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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Kondajji A, Klingler M, Tu C, Kelley R, El-Hayek K, Rodriquez J, Cline M, Fathalizadeh A, Allemang M. Gastroparesis with concomitant gastrointestinal dysmotility is not a contraindication for per-oral pyloromyotomy (POP). Surg Endosc 2022; 36:4226-4232. [PMID: 34642799 DOI: 10.1007/s00464-021-08756-9] [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: 02/08/2021] [Accepted: 09/27/2021] [Indexed: 01/29/2023]
Abstract
INTRODUCTION Per-oral pyloromyotomy (POP or G-POEM) provides significant short-term improvements in symptoms and objective emptying for patients with medically refractory gastroparesis, but it is unclear if patients with gastroparesis and co-existing dysmotility (small bowel or colonic delay) also benefit. In this study, we used wireless motility capsule (WMC) data to measure outcomes in patients with isolated gastroparesis (GP) and gastroparesis with co-existing dysmotility (GP + Dys) who underwent POP. METHODS We retrospectively analyzed patients who had POP and completed WMC data during their evaluation of intestinal dysmotility. WMC data were reviewed to identify patients who demonstrated isolated GP or GP + Dys. Each patient's pre-op and post-op Gastroparesis Cardinal Symptom Index (GCSI) and 4-h solid-phase scintigraphy gastric emptying studies (GES) scores were compared to evaluate improvement. RESULTS Of the entire cohort (n = 73), 89% were female with a mean age of 47.0 ± 15.0 years old. Gastroparesis etiologies were divided among idiopathic (54.8%), diabetic (26%), postsurgical (8.2%), autoimmune (5.5%), and multifactorial (5.5%). Forty-one patients (56%) had GP and 32 patients (44%) had GP + Dys. GCSI improved after POP whether the patient had isolated GP (- 12.31, p < 0.001) or GP + Dys (- 9.58, p < 0.001); however, there was no significant difference in total GCSI improvement between the two groups. A subset of patients had postoperative GES available (n = 47). In the isolated GP and GP + Dys cohorts, 15/28 (54%) and 12/19 (63%) patients had normal post-op 4-h GES, respectively, but no statistical difference between the two groups. CONCLUSION Patients with medically refractory gastroparesis with and without concomitant gastrointestinal dysmotility show short-term subjective and objective improvement after POP. Concomitant small bowel or colonic dysmotility should not deter physicians from offering POP in carefully selected patients with gastroparesis.
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Affiliation(s)
- Abhiram Kondajji
- Digestive Disease and Surgical Institute, Cleveland Clinic, Cleveland, OH, USA.
- General Surgery Resident, Cleveland Clinic-South Pointe Hospital, 20000 Harvard Road, Warrensville Height, OH, 44122, USA.
| | - Michael Klingler
- Digestive Disease and Surgical Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Chao Tu
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Rebecca Kelley
- Dermatology and Plastic Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | - John Rodriquez
- Digestive Disease and Surgical Institute, Cleveland Clinic, Abu Dhabi, UAE
| | - Michael Cline
- Digestive Disease and Surgical Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Alisan Fathalizadeh
- Digestive Disease and Surgical Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Matthew Allemang
- Digestive Disease and Surgical Institute, Cleveland Clinic, Cleveland, OH, USA
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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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Rappaport JM, Raja S, Gabbard S, Thuita L, Sanaka MR, Blackstone EH, Ahmad U. Endoscopic Pyloromyotomy Is Feasible and Effective in Improving Post–Lung Transplant Gastroparesis. J Thorac Cardiovasc Surg 2021; 164:711-719.e4. [DOI: 10.1016/j.jtcvs.2021.10.063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 09/21/2021] [Accepted: 10/12/2021] [Indexed: 02/07/2023]
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Gregor L, Wo J, DeWitt J, Yim B, Siwiec R, Nowak T, Mendez M, Gupta A, Dickason D, Stainko S, Al-Haddad M. Gastric peroral endoscopic myotomy for the treatment of refractory gastroparesis: a prospective single-center experience with mid-term follow-up (with video). Gastrointest Endosc 2021; 94:35-44. [PMID: 33373646 DOI: 10.1016/j.gie.2020.12.030] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 12/09/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Gastroparesis (GP) is a multifactorial disease associated with a large burden on the health care systems. Pyloric-directed therapies including gastric peroral endoscopic myotomy (G-POEM) can be effective in improving patient quality of life and symptom severity. We report on the safety and efficacy of G-POEM and its impact on the quality of life of patients managed at a large referral center. METHODS Consecutive patients with confirmed GP referred for G-POEM due to failure of medical therapy were included. All patients were assessed at baseline and then at 1, 3, 6, and 12 and 24 months after G-POEM using validated symptom and quality of life instruments, including the Gastroparesis Cardinal Symptom Index (GCSI), Patient Assessment of Gastrointestinal Disorders Symptom Severity Index (PAGI-SYM), and 36-Item Short Form Survey (SF-36). Patients were evaluated before and 6 months after the procedure with EGD, 4-hour scintigraphy, and pyloric EndoFLIP. Technical success was defined as the ability to perform full-thickness pyloromyotomy. Clinical response was defined as an improvement of ≥1 point on GCSI. RESULTS Fifty-two patients (median age, 48 years; range, 25-80 years, 88% female) underwent G-POEM between February 2018 and September 2020 for the following phenotypes: vomiting-predominant (n=30), dyspepsia-predominant (n=16), and regurgitation-predominant (n=6) GP. The technical success rate was 100%. Adverse events were noted in 3 of 52 patients (5.77%), and were all managed successfully endoscopically. Clinical response was achieved in 68%, 58%, and 48% of patients at 1-month, 6-month, and 12-month follow-up (P < .001, P < .001, and P < .01, respectively). When classified by the cause of GP, the clinical response rates were diabetic GP 64% (11 of 17), postsurgical GP 67% (6 of 9), and idiopathic GP 72% (13 of 18). A statistically significant improvement in PAGI-SYM scores was observed at 1, 3, 6, 12, and 24 months, in addition to significant improvement in several domains of SF-36. Mean 4-hour gastric emptying was reduced 6 months after G-POEM (10.2%) compared with baseline (36.5%, P < .001). We report a significant reduction in the number of emergency department visits and days spent in the hospital up to 24 months after G-POEM. CONCLUSIONS G-POEM appears to be a safe and feasible treatment alternative for refractory GP with significant short-term and mid-term improvements in overall symptoms, quality of life scores, and health care utilization.
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Affiliation(s)
- Lennon Gregor
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - John Wo
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - John DeWitt
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Brandon Yim
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Robert Siwiec
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Thomas Nowak
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Martha Mendez
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Anita Gupta
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Destenee Dickason
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Sarah Stainko
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Mohammad Al-Haddad
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Ragi O, Jacques J, Branche J, Leblanc S, Vanbiervliet G, Legros R, Pioche M, Rivory J, Chaussade S, Barret M, Wallenhorst T, Barthet M, Kerever S, Gonzalez JM. One-year results of gastric peroral endoscopic myotomy for refractory gastroparesis: a French multicenter study. Endoscopy 2021; 53:480-490. [PMID: 32575130 DOI: 10.1055/a-1205-5686] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Data on the long-term outcomes of gastric peroral endoscopic myotomy (G-POEM) for refractory gastroparesis are lacking. We report the results of a large multicenter long-term follow-up study of G-POEM for refractory gastroparesis. METHODS This was a retrospective multicenter study of all G-POEM operations performed in seven expert French centers for refractory gastroparesis with at least 1 year of follow-up. The primary endpoint was the 1-year clinical success rate, defined as at least a 1-point improvement in the Gastroparesis Cardinal Symptom Index (GCSI). RESULTS 76 patients were included (60.5 % women; age 56 years). The median symptom duration was 48 months. The median gastric retention at 4 hours (H4) before G-POEM was 45 % (interquartile range [IQR] 29 % - 67 %). The median GCSI before G-POEM was 3.6 (IQR 2.8 - 4.0). Clinical success was achieved in 65.8 % of the patients at 1 year, with a median rate of reduction in the GCSI score of 41 %. In logistic regression analysis, only a high preoperative GCSI satiety subscale score was predictive of clinical success (odds ratio [OR] 3.41, 95 % confidence interval [CI] 1.01 - 11.54; P = 0.048), while a high rate of gastric retention at H4 was significantly associated with clinical failure (OR 0.97, 95 %CI 0.95 - 1.00; P = 0.03). CONCLUSIONS The results confirm the efficacy of G-POEM for the treatment of refractory gastroparesis, as evidenced by a 65.8 % clinical success rate at 1 year. Although G-POEM is promising, prospective sham-controlled trials are urgently needed to confirm its efficacy and identify the patient populations who will benefit most from this procedure.
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Affiliation(s)
- Olivier Ragi
- Service de gastroentérologie, CHU Limoges, France
| | - Jérémie Jacques
- Service de gastroentérologie, CHU Limoges, France.,CNRS, XLIM, UMR 7252, Limoges, France
| | - Julien Branche
- Service de gastroentérologie, CHU Claude Huriez, Lille, France
| | - Sarah Leblanc
- Service de gastroentérologie, APHP, Hôpital Cochin, Paris, France
| | | | | | - Mathieu Pioche
- Service de gastroentérologie, HCL Edouard Herriot, Lyon, France
| | - Jérôme Rivory
- Service de gastroentérologie, HCL Edouard Herriot, Lyon, France
| | | | | | | | - Marc Barthet
- Service de gastroentérologie, APHM, Hôpital Nord, Marseille, France
| | - Sébastien Kerever
- Department of Anesthesiology and Critical Care, Saint Louis Lariboisière Fernand Widal University Hospital, AP-HP, Paris, France
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14
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Li P, Ma B, Gong S, Zhang X, Li W. Gastric per-Oral Endoscopic Myotomy for Refractory Gastroparesis: A Meta-Analysis. J Gastrointest Surg 2021; 25:1108-1116. [PMID: 32394124 DOI: 10.1007/s11605-020-04520-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Accepted: 01/14/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND The emerging gastric per-oral endoscopic myotomy (G-POEM) is becoming an alternative treatment method for gastroparesis. This study aimed to evaluate the feasibility and safety of G-POEM for gastroparesis. METHODS Relevant publications were identified through searching PubMed, EMBASE, Cochrane Library, and Web of Science before April 1, 2019. Studies presenting the clinical data of G-POEM for the treatment of gastroparesis were included. Data about effectiveness and safety were extracted, pooled, and analyzed. Forest plots were graphed based on random effects models. RESULTS A total of 272 patients representing 8 studies were eligible for analysis. The pooled rates of GCSI at preprocedure, 1-3 months, 6 months, and 12 months, were 3.25 (95% CI, 2.75-3.75), 1.80 (95% CI, 1.10-2.49), 1.56 (95% CI, 0.45-2.68), and 1.10 (95% CI, 0.75-1.45), respectively. The pooled results of 4-h GES pre- and post-G-POEM were 41.89% (95% CI, 32.75-51.03%) and 16.48% (95% CI, 9.83-23.14%), respectively. Furthermore, the pooled clinical response rate was 84% (95% CI, 77-89%). The GES improvement rate and GES normal rate were also analyzed, and the results were 84% (95% CI, 77-90%) and 53% (95% CI, 39-66%), respectively. Finally, the pooled adverse events rate was 12% (95% CI, 6-19%). CONCLUSIONS G-POEM was shown to be feasible and safe for the treatment of gastroparesis with various etiologies, which could be a potential first-line therapy for certain patients. Future studies are needed to investigate the appropriate patients for G-POEM to explore the "most beneficial" subgroup of patients.
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Affiliation(s)
- Peiwen Li
- Department of Thoracic Surgery, The First Hospital of China Medical University, No.155 North Nanjing Street, Shenyang, 110001, People's Republic of China
| | - Bin Ma
- Department of Colorectal Surgery, Liaoning Cancer Hospital and Institute, Cancer Hospital of China Medical University, No. 44 Xiaoheyan Road, Dadong District, Shenyang, 110042, Liaoning Province, People's Republic of China
| | - Shulei Gong
- Department of Thoracic Surgery, The First Hospital of China Medical University, No.155 North Nanjing Street, Shenyang, 110001, People's Republic of China
| | - Xinyu Zhang
- Department of Thoracic Surgery, The First Hospital of China Medical University, No.155 North Nanjing Street, Shenyang, 110001, People's Republic of China
| | - Wenya Li
- Department of Thoracic Surgery, The First Hospital of China Medical University, No.155 North Nanjing Street, Shenyang, 110001, People's Republic of China.
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Conchillo JM, Straathof JWA, Mujagic Z, Brouns JH, Bouvy ND, Keszthelyi D, Masclee AA. Gastric peroral endoscopic pyloromyotomy for decompensated gastroparesis: comprehensive motility analysis in relation to treatment outcomes. Endosc Int Open 2021; 9:E137-E144. [PMID: 33532550 PMCID: PMC7834704 DOI: 10.1055/a-1311-0859] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 10/05/2020] [Indexed: 12/26/2022] Open
Abstract
Background and study aims There are no reliable data to predict which patients with gastroparesis (GP) would benefit the most from gastric peroral endoscopic pyloromyotomy (G-POEM). The aim of the present study was to assess whether antro-duodenal motility patterns and pyloric distensibility can predict the outcome of G-POEM in patients with decompensated GP. Patients and methods In an open-label study, patients with GP and refractory symptoms were eligible for treatment with G-POEM if treatment attempts according to a standardized stepwise protocol had failed. Baseline assessment included Gastroparesis Cardinal Symptom Index (GCSI), C13-octanoic gastric emptying breath test and high-resolution antro-duodenal manometry. Pyloric distensibility using EndoFlip measurements was assessed at baseline and 3 months after the procedure. Explorative analyses were performed on potential predictors of response using logistic regression analyses. Results Twenty-four patients with decompensated GP underwent G-POEM. At baseline, 78.3 % and 61.9 % of patients showed antral hypomotility and neuropathic motor patterns, respectively. The technical success rate was 100 % (24/24). Mean GCSI improved significantly at 3, 6, and 12 months after G-POEM ( P = 0.01). Median distensibility index (DI) improved significantly as compared with baseline (7.5 [6.9;11.7] vs. 5.3[3.1;8.1], P = 0.004). A significant correlation was found between clinical response at 6 months and pyloric DI improvement ( P = 0.003). No potential predictors of clinical response after G-POEM could be identified in an explorative analysis. Conclusions G-POEM improved pyloric distensibility patterns in patients with decompensated GP. Clinical response at 6 months after G-POEM was associated with pyloric distensibility improvement. However, no potential predictors of response could be identified from either antro-duodenal motility patterns or pyloric distensibility.
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Affiliation(s)
- José M. Conchillo
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Jan Willem A. Straathof
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Zlatan Mujagic
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Jenny H. Brouns
- Department of Dietetics, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Nicole D. Bouvy
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Daniel Keszthelyi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Ad A.M. Masclee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
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Fathalizadeh A, Klingler M, Landreneau J, Allemang M, Rodriguez J, Ponsky J, El-Hayek K. Real-time intraoperative functioning lumen imaging probe during endoscopic per-oral pyloromyotomy (pop). Surg Endosc 2021; 36:745-752. [PMID: 33427911 PMCID: PMC8741673 DOI: 10.1007/s00464-020-08237-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Accepted: 12/08/2020] [Indexed: 01/12/2023]
Abstract
Background Endoscopic per-oral pyloromyotomy (POP) has emerged as a safe and effective first line option in medically refractory gastroparesis. Determining the appropriate extent of the pyloromyotomy continues to present a challenge as there are no standardized tools for measuring changes in pyloric distensibility during the procedure. The objective of this study was to evaluate the utility of using impedance planimetry with endoscopic functional luminal imaging probe (FLIP) to measure changes in pyloric distensibility after POP, and to compare these changes with improvement in symptoms and objective gastric emptying. Methods Patients with medically refractory gastroparesis underwent POP with FLIP measurements of the pylorus (EndoFLIP®, Medtronic, Fridley MN). FLIP measurements, as well as changes in symptoms measured by the validated gastroparesis cardinal symptom index (GCSI) and scintigraphic gastric emptying studies (GES), were evaluated before and after POP. Results A total of 14 patients underwent measurement with FLIP during POP, 12 of whom had pre- and post-POP measurements. Mean pyloric diameter increased by 1.4 mm, from 13.9 mm to 15.3 mm (p = 0.0012). Mean distensibility index increased from 6.2 mm2/mmHg to 9.1 mm2/mmHg (p = 0.0074). Successful division of the pylorus was achieved in 100% of patients with a mean operative time of 36 min and no perioperative complications. The mean length of stay was 0.7 days (0–3 days). Post-POP mean GCSI score improved from 2.97 to 2.28 at a mean follow-up time of 27 days (p < 0.001). Objective improvement in gastric emptying was observed in 80% of patients with scintigraphic GES, with mean four-hour retention decreasing from 46.3% to 32.4% (p < 0.007). Conclusions FLIP is a safe and feasible tool to provide objective measurements during POP. Larger cohorts with longer follow-up are required to determine if measured improvements in pyloric diameter and distensibility are predictive of sustained improvements in GCSI and GES.
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Affiliation(s)
- Alisan Fathalizadeh
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Michael Klingler
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Joshua Landreneau
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Matthew Allemang
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - John Rodriguez
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.,Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Jeffrey Ponsky
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.,Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Kevin El-Hayek
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.,Division of General Surgery, MetroHealth System, Cleveland, OH, USA.,Case Western Reserve University School of Medicine, Cleveland, OH, USA
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17
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Shanbhag AB, Thota PN, Sanaka MR. Recent advances in third space or intramural endoscopy. World J Gastrointest Endosc 2020; 12:521-531. [PMID: 33362905 PMCID: PMC7739143 DOI: 10.4253/wjge.v12.i12.521] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 10/18/2020] [Accepted: 11/29/2020] [Indexed: 02/06/2023] Open
Abstract
Third space endoscopy or intramural endoscopy is based on the principle that the deeper layers of the gastrointestinal tract can be accessed by tunneling in the submucosal space and maintaining the integrity of the overlying mucosa. The era of third space endoscopy started with peroral endoscopic myotomy (POEM) for treatment of achalasia and has expanded to treat various other gastrointestinal disorders. The technique is also currently used for treatment of refractory gastroparesis, Zenker’s diverticulum (ZD), resection of subepithelial tumors and early cancers of the gastrointestinal tract and Hirschsprung’s disease (HD). These procedures are rapidly emerging as minimally invasive alternatives to conventional surgery. They are safe and effective with excellent outcomes. This review focuses on the evolution and current applications of third space endoscopy in various gastrointestinal disorders. Key points: (1) Third space or intramural endoscopy initially started with the POEM procedure for treatment of achalasia; (2) Advancements in procedural techniques have expanded its application to treat other gastrointestinal disorders such as refractory gastroparesis, ZD, HD, resection of subepithelial tumors and early gastrointestinal cancers; (3) These procedures are highly effective with excellent outcomes and low complication rates; and (4) Third space endoscopic procedures are rapidly emerging as minimally invasive alternatives to conventional surgery.
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Affiliation(s)
- Akshay B Shanbhag
- Department of Gastroenterology, Cleveland Clinic Foundation, Cleveland, OH 44195, United States
| | - Prashanthi N Thota
- Department of Gastroenterology, Cleveland Clinic Foundation, Cleveland, OH 44195, United States
| | - Madhusudhan R Sanaka
- Department of Gastroenterology, Cleveland Clinic Foundation, Cleveland, OH 44195, United States
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18
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Abstract
Peroral pyloromyotomy, an innovative intramural endoscopic surgery procedure, is a successful management option for appropriately selected patients who suffer from medically refractory gastroparesis. Gastroparesis is a debilitating disorder of the gastrointestinal tract, which significantly decreases quality of life and overall survival. This article describes the history and background, the indications for, the diagnosis of, and the preparation, technique, and short-term outcomes of peroral pyloromyotomy.
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Tat C, Barajas-Gamboa JS, Kroh M. Principles of Intramural Surgery. Surg Clin North Am 2020; 100:1169-1182. [PMID: 33128886 DOI: 10.1016/j.suc.2020.08.003] [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] [Indexed: 11/17/2022]
Abstract
Intramural surgery is a minimally invasive surgical technique based on flexible endoscopy. The first step involves the initial mucosal incision for entry point. Then a submucosal tunnel is dissected to the site of the target anatomy. The procedure performed may include myotomy or lesion removal. When complete, the initial mucosal incision is closed. This technique separates the mucosal flap from the surgical site, minimizing the risk of full-thickness perforation and gastrointestinal leakage. Peroral endoscopic myotomy is the most studied application of intramural surgery but other procedures have emerged. This article explores principles of intramural surgery and summarizes its applications.
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Affiliation(s)
- Christine Tat
- Digestive Disease Institute, Cleveland Clinic Abu Dhabi, PO Box 112412, Abu Dhabi, United Arab Emirates
| | - Juan S Barajas-Gamboa
- Digestive Disease Institute, Cleveland Clinic Abu Dhabi, PO Box 112412, Abu Dhabi, United Arab Emirates
| | - Matthew Kroh
- Digestive Disease Institute, Cleveland Clinic Abu Dhabi, Cleveland Clinic Lerner College of Medicine, PO Box 112412, Abu Dhabi, United Arab Emirates.
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20
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Endoscopic Equipment-From Simple to Advanced. Surg Clin North Am 2020; 100:993-1019. [PMID: 33128892 DOI: 10.1016/j.suc.2020.08.002] [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: 10/23/2022]
Abstract
Flexible endoscopic procedures, such as esophagogastroduodenoscopies and colonoscopies, allow for diagnosis and treatment of numerous gastrointestinal disorders. Advanced endoscopic procedures, such as endoscopic ultrasounds, endoscopic retrograde cholangiopancreatography, and balloon enteroscopies, offer therapeutic options that are minimally invasive and effective. As technology advances, the equipment and tools in an endoscopist's armamentarium continue to grow. This article highlights key endoscopic equipment and supplies, from simple to advanced.
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Abstract
Surgeons have been involved, since the beginning, in the development and evolution of endoscopy. They have been instrumental in developing new methods and have been actively involved in most of the therapeutic applications. The continued evolution of endoscopic technique is inevitable and will involve the integration of new technology with innovative thinking.
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Affiliation(s)
- Jeffrey L Ponsky
- Department of General Surgery, Cleveland Clinic, Desk A100, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
| | - Andrew T Strong
- Department of General Surgery, Cleveland Clinic, Desk A100, 9500 Euclid Avenue, Cleveland, OH 44195, USA
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Per Oral Pyloromyotomy for Gastroparesis: A Systematic Review of the Current Literature and Future Recommendations. GASTROINTESTINAL DISORDERS 2020. [DOI: 10.3390/gidisord2040038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background: Gastric per oral endoscopic myotomy (GPOEM) was developed as a therapeutic option for gastroparesis after the pylorus was identified as a key target for gastroparesis management. This study includes a systematic literature review of studies in which GPOEM was utilized as therapy for gastroparesis. Methods: A literature search was conducted in three databases (MEDLINE, Scopus and Embase) of articles that included the keywords “GPOEM”, “Gastric per oral endoscopy myotomy” or “per oral pyloromyotomy” and “Gastroparesis” in the abstract or title. The search covered articles published until 29 February 2020. Results: A total of 139 articles were identified. Only 15 articles met the final inclusion criteria and were retrieved for qualitative data synthesis. Conclusion: GPOEM for gastroparesis is shown to have a high success rate among the studies but data interpretations are limited because of small sample sizes and short follow-up. Subjective and objective data prior to and post-GPOEM will be mandatory to establish credibility. The procedure is technically feasible and safe based on the limited studies available.
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23
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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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Parsi MA, Jirapinyo P, Abu Dayyeh BK, Bhutani MS, Chandrasekhara V, Krishnan K, Kumta NA, Melson J, Pannala R, Trikudanathan G, Trindade AJ, Sethi A, Watson RR, Maple JT, Lichtenstein DR. Techniques and devices for the endoscopic treatment of gastroparesis (with video). Gastrointest Endosc 2020; 92:483-491. [PMID: 32684298 DOI: 10.1016/j.gie.2020.03.3857] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 03/30/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Gastroparesis is a symptomatic chronic disorder of the stomach characterized by delayed gastric emptying in the absence of mechanical obstruction. Several endoscopic treatment modalities have been described that aim to improve gastric emptying and/or symptoms associated with gastroparesis refractory to dietary and pharmacologic management. METHODS In this report we review devices and techniques for endoscopic treatment of gastroparesis, the evidence regarding their efficacy and safety, and the financial considerations for their use. RESULTS Endoscopic modalities for treatment of gastroparesis can be broadly categorized into pyloric, nonpyloric, and nutritional therapies. Pyloric therapies such as botulinum toxin injection, stent placement, pyloroplasty, and pyloromyotomy specifically focus on pylorospasm as a therapeutic target. These interventions aim to reduce the pressure gradient across the pyloric sphincter, with a resultant improvement in gastric emptying. Nonpyloric therapies, such as venting gastrostomy and gastric electrical stimulation, are intended to improve symptoms. Nutritional therapies, such as feeding tube placement, aim to provide nutritional support. CONCLUSIONS Several endoscopic interventions have shown utility in improving the quality of life and symptoms of select patients with refractory gastroparesis. Methods to identify which patients are best suited for a specific treatment are not well established. Endoscopic pyloromyotomy is a relatively recent development that may prove to be the preferred pyloric-directed intervention, although additional and longer-term outcomes are needed.
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Affiliation(s)
- Mansour A Parsi
- Section for Gastroenterology and Hepatology, Tulane University Health Sciences Center, New Orleans, Louisiana, USA
| | - Pichamol Jirapinyo
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Barham K Abu Dayyeh
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Manoop S Bhutani
- Department of Gastroenterology Hepatology and Nutrition, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Vinay Chandrasekhara
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kumar Krishnan
- Division of Gastroenterology, Department of Internal Medicine, Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Nikhil A Kumta
- Division of Gastroenterology, Mount Sinai Hospital, New York, New York, USA
| | - Joshua Melson
- Division of Gastroenterology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Rahul Pannala
- Division of Digestive Diseases, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Guru Trikudanathan
- Department of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Arvind J Trindade
- Department of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
| | - Amrita Sethi
- Department of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, New Hyde Park, New York, USA
| | - Rabindra R Watson
- New York-Presbyterian Medical Center/Columbia University Medical Center, New York, New York, USA
| | - John T Maple
- Department of Gastroenterology, Interventional Endoscopy Services, California Pacific Medical Center, San Francisco, California, USA
| | - David R Lichtenstein
- Division of Digestive Diseases and Nutrition, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
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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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Hasler WL. Targeting Treatment of Gastroparesis: Use of Clinical Tests to Guide Treatments. Gastroenterol Clin North Am 2020; 49:519-538. [PMID: 32718568 DOI: 10.1016/j.gtc.2020.04.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
Gastroparesis presents with nausea, vomiting, and other upper gut symptoms, and is diagnosed by confirming delayed gastric emptying. A related condition, chronic unexplained nausea and vomiting, has similar symptoms but with normal emptying. Both conditions are managed using therapies with diverse mechanisms of action. Even though prokinetic treatments are proposed to improve gastroparesis by accelerating gastric emptying, there is limited evidence that they provide benefit by virtue of transit stimulating effects. Other tests can delineate alterations in other gut sensorimotor parameters in patients with suspected gastroparesis, but their relation to symptoms and their capability to guide treatment are largely unproved.
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Affiliation(s)
- William L Hasler
- Division of Gastroenterology and Hepatology, University of Michigan Health System, 3912 Taubman Center, SPC 5362, Ann Arbor, MI 48109, USA.
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Brown AM, Pryor AD, Docimo S. Per oral pyloromyotomy utilizing a lesser curvature approach: how we do it. Surg Endosc 2020; 34:5168-5171. [DOI: 10.1007/s00464-020-07802-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 07/07/2020] [Indexed: 12/17/2022]
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Uemura KL, Chaves D, Bernardo WM, Uemura RS, de Moura DTH, de Moura EGH. Peroral endoscopic pyloromyotomy for gastroparesis: a systematic review and meta-analysis. Endosc Int Open 2020; 8:E911-E923. [PMID: 32617395 PMCID: PMC7297609 DOI: 10.1055/a-1119-6616] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 01/06/2020] [Indexed: 02/07/2023] Open
Abstract
Background and aim Gastric peroral endoscopic pyloromyotomy (G-POEM) is a new therapeutic option for refractory gastroparesis (GP). A systematic review and meta-analysis was conducted to assess the effectiveness of G-POEM in refractory GP. For the quality of evidence, we used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. Methods We performed a literature search using MEDLINE, Embase, Cochrane library, LILACS and the Science citation index for studies related to G-POEM from the inception of its technique through January 2019. We selected studies that analyzed the gastroparesis cardinal symptom index (GCSI) and 4-hour solid-phase gastric emptying scintigraphy (GES) before and after the procedure to verify the efficacy of G-POEM, the main outcome measured. An analysis was performed using RevMan 5.3. Results Ten studies comprising 281 patients were included in this systematic review. The pooled mean difference in GCSI following the procedure was 1.76 (95 % CI: [1.43, 2.08], I 2 = 72 %). We also performed GCSI subgroup analysis by follow-up duration that showed a pooled mean difference of 1.84 (95 % CI: [1.57, 2.12], I 2 = 71 %). The pooled mean difference in GES after the procedure was 26.28 (95 % CI: [19.74, 32.83], I 2 = 87 %), corresponding to a significant drop in percentage values of the gastric retention 4-hour scintigraphy. Conclusion This meta-analysis demonstrates that G-POEM is effective and shows promising outcomes in the clinical response and gastric emptying scintigraphy for gastroparesis. Therefore, it should be considered in the management of refractory gastroparesis.
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Affiliation(s)
- Karime Lucas Uemura
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Dalton Chaves
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Wanderley M. Bernardo
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Ricardo Sato Uemura
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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Abstract
Gastroparesis is characterized by delayed gastric emptying, with symptoms such as nausea, vomiting and abdominal pain, in the absence of mechanical obstruction. In most cases, it is idiopathic although diabetes mellitus is another leading cause. The physiology of gastric emptying is a complex process which is influenced by various inputs including the central nervous system, enteric nervous system and gut hormones. Developments in our understanding of gastroparesis have now demonstrated dysfunction in these systems, thus disrupting normal gastric emptying. Once mechanical obstruction is excluded, gastric scintigraphy remains the gold standard for diagnosis although wireless motility capsule and breath testing are alternative methods for diagnosis. Treatment for gastroparesis is challenging, and widely available therapies are often limited either by their poor evidence for efficacy or concerns over their long-term safety profile. Novel prokinetic agents have shown initial promise in clinical trials, and new endoscopic techniques such as gastric per-oral endoscopic myotomy are emerging. These new treatment modalities may provide an option in refractory gastroparesis with the adage of reduced morbidity compared to surgical treatments.
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Affiliation(s)
- A Sullivan
- Homerton University Hospital, London, UK
| | | | - A Ruban
- Department of Surgery and Cancer, Imperial College, London, UK.
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Chavan R, Nabi Z, Reddy DN. Adverse events associated with third space endoscopy: Diagnosis and management. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2020. [DOI: 10.18528/ijgii200010] [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] [Indexed: 12/22/2022] Open
Affiliation(s)
- Radhika Chavan
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Zaheer Nabi
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
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Spadaccini M, Maselli R, Chandrasekar VT, Anderloni A, Carrara S, Galtieri PA, Di Leo M, Fugazza A, Pellegatta G, Colombo M, Palma R, Hassan C, Sethi A, Khashab MA, Sharma P, Repici A. Gastric peroral endoscopic pyloromyotomy for refractory gastroparesis: a systematic review of early outcomes with pooled analysis. Gastrointest Endosc 2020; 91:746-752.e5. [PMID: 31809720 DOI: 10.1016/j.gie.2019.11.039] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 11/19/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Gastroparesis (GP) is a chronic debilitating condition. Prior pyloric-targeted procedures are either invasive or have questionable efficacy. Gastric peroral pyloromyotomy (G-POEM) has been proposed as a minimally invasive approach. We performed a pooled analysis to evaluate the efficacy and safety of G-POEM for GP. METHODS Electronic databases (Medline, Scopus, EMBASE) were searched up to January 2019. Studies including patients who underwent G-POEM for GP were eligible. Procedural, clinical, and safety outcomes were assessed by pooling data with a random- or fixed-effect model according to the degree of heterogeneity to obtain a proportion with a 95% confidence interval. RESULTS Ten studies were eligible for inclusion (292 patients), and 2 of the 10 studies were prospective. Seven studies were performed in the United States, 2 in France, and 1 in China. Endoscopic pyloromyotomy was feasible in all patients. Significant symptomatic improvement was achieved after 83.9% of procedures (mean follow-up, 7.8 ± 5.5 months). When comparing the mean values of pre- and postprocedural scintigraphic evolution, there was a significant decrease of the residual percentage at 2 and 4 hours. The overall adverse events rate was 6.8%. CONCLUSIONS G-POEM appears to be a promising approach for GP in terms of safety and efficacy outcomes in the short term.
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Affiliation(s)
- Marco Spadaccini
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center and Humanitas University, Rozzano, Italy
| | - Roberta Maselli
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center and Humanitas University, Rozzano, Italy
| | - Viveksandeep Thoguluva Chandrasekar
- Division of Gastroenterology and Hepatology, University of Kansas School of Medicine, Kansas City, Kansas, USA; Division of Gastroenterology and Hepatology, Veteran Affairs Medical Center, Kansas City, Missouri, USA
| | - Andrea Anderloni
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center and Humanitas University, Rozzano, Italy
| | - Silvia Carrara
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center and Humanitas University, Rozzano, Italy
| | - Piera Alessia Galtieri
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center and Humanitas University, Rozzano, Italy
| | - Milena Di Leo
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center and Humanitas University, Rozzano, Italy
| | - Alessandro Fugazza
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center and Humanitas University, Rozzano, Italy
| | - Gaia Pellegatta
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center and Humanitas University, Rozzano, Italy
| | - Matteo Colombo
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center and Humanitas University, Rozzano, Italy
| | - Rossella Palma
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center and Humanitas University, Rozzano, Italy
| | - Cesare Hassan
- Digestive Endoscopy Unit, Nuovo Regina Margherita Hospital, Rome, Italy
| | - Amrita Sethi
- Division of Gastroenterology and Hepatology, New York-Presbyterian Medical Center/Columbia University Medical Center, New York, New York, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Prateek Sharma
- Division of Gastroenterology and Hepatology, University of Kansas School of Medicine, Kansas City, Kansas, USA; Division of Gastroenterology and Hepatology, Veteran Affairs Medical Center, Kansas City, Missouri, USA
| | - Alessandro Repici
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center and Humanitas University, Rozzano, Italy
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Yan J, Tan Y, Zhou B, Zhang S, Wang X, Liu D. Gastric per-oral endoscopic myotomy (G-POEM) is a promising treatment for refractory gastroparesis: a systematic review and meta-analysis. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2020; 112:219-228. [PMID: 32081015 DOI: 10.17235/reed.2020.6559/2019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
AIM to evaluate the efficacy and safety of gastric per-oral endoscopic myotomy (G-POEM) for the treatment of refractory gastroparesis. METHODS PubMed, Embase and Cochrane databases were searched and used for study inclusion. Clinical studies since January 2013 to October 2019 were identified as suitable for inclusion. Conference papers, review articles, case reports, animal studies, letters, studies with repetitive data, studies that did not mention the Gastroparesis Cardinal Symptom Index (GCSI) score/gastric emptying scintigraphy (GES) hours or were not indicated in the standard form were excluded. GCSI score, GCSI reduction, gastric emptying scintigraphy at four hours (GES-4h) and GES time (GET) reduction were considered as major indexes and the meta-analysis was achieved using Review Manager 5.3. Research bias was measured according to Cochrane handbook. RESULTS nine studies were included with a total of 235 patients that underwent G-POEM, and the technical success rate was 100%. After G-POEM, patients reported changes in GCSI score (6/9 studies, mean difference 1.41 [CI: 0.93, 1.88], p < 0.0001), GCSI reduction (8/9 studies, odds ratio 3.00 [CI: 2.24, 4.03], p < 0.0001), GES-4h (8/9 studies, mean difference 23.78 [CI: 19.88, 27.68], p < 0.00001) and GET reduction (6/9 studies, odds ratio 3.50 [CI: 2.12, 5.78], p < 0.00001). The intra-procedure complication rate was 5.1% (12/235), including capnoperitoneum (seven cases) and accidental mucotomy (five cases). The post-procedure complication rate was 6.8% (16/235), including abdominal pain (three cases), bleeding (three cases), ulcer (one case), difficulty swallowing (one case) and others (eight cases). Both per- and post-procedure complications were easily managed by conservative or endoscopic treatments. CONCLUSION the results show that gastroparesis patients can benefit from G-POEM, the success rate was impressive and the complication rate was relatively low. However, caution is necessary when interpreting the results, primarily due to the limitations of uncontrolled studies. Randomized control studies are still needed for further evaluations.
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Affiliation(s)
- Jin Yan
- Gastroenterology, The Second Xiangya Hospital. Central South University, China
| | - Yuyong Tan
- Gastroenterology, The Second Xiangya Hospital. Central South University, China
| | - Bingyi Zhou
- Gastroenterology, The Second Xiangya Hospital. Central South University, China
| | - Shilan Zhang
- Gastroenterology, The Second Xiangya Hospital. Central South University, China
| | - Xuehong Wang
- Gastroenterology, The Second Xiangya Hospital. Central South University, China
| | - Deliang Liu
- Gastroenterology, The Second Xiangya Hospital. Central South University, China
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Sleeve gastrectomy for treatment of delayed gastric emptying-indications, technique, and results. Langenbecks Arch Surg 2020; 405:107-116. [PMID: 31956952 DOI: 10.1007/s00423-020-01856-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 01/14/2020] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Delayed gastric emptying (DGE) can be caused by gastric motility disorders such as gastroparesis with idiopathic background, diabetic neuropathy, or postsurgical nerve damage. Currently, a variety of endoscopic and surgical treatment options are available. We noted clinical improvement of gastric emptying with reduction of the gastric fundus following both fundoplication and fundectomy. As a consequence, we explored the effect of sleeve gastrectomy on gastric emptying. The focus of this paper is to investigate the role of laparoscopic sleeve gastrectomy (LSG) in the treatment of gastroparesis. METHODS Patients with symptoms suggestive of gastroparesis received diagnostic work-up (gastric emptying scintigraphy and/or Radiographic Barium-Sandwich Emptying studies). Patients with fundic emptying problems and moderate gastric dilation were selected for a LSG. All perioperative parameters were documented regarding patients characteristics, complications, and outcomes expressed as symptoms and quality of life (GIQLI gastrointestinal quality of life index). Assessment of DGE: Barium Emptying Radigraphy Index (BERI) 0-5. RESULTS From 122 patients with gastroparesis, 19 patients were selected for LSG (mean age 54 years (23-68); 10 males/9 females. Morbidity 2/19; no mortality; follow-up mean 24 months (12-60); preop/postop: BERI: 2, 31/1, 27 (p < 0.01); we noted significant improvement of the quality of life (preoperative GIQLI 78 (44-89)) to postoperative values of 114 (range 87-120) (p < 0.0001). Preoperative median BMI of these 19 patients was 24 [1-10], which was not significantly changed in the 15 patients at > 1 year follow-up with 23 [1-8]. Postoperative recurrence of DGE occurred in 3 patients who were reoperated after >1 year follow-up. CONCLUSION LSG is a potential surgical treatment option for selected patients with gastroparesis and fundic emptying problems.
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Safety and Feasibility of Per-Oral Pyloromyotomy as Augmentative Therapy after Prior Gastric Electrical Stimulation for Gastroparesis. J Am Coll Surg 2019; 229:589-595. [PMID: 31610231 DOI: 10.1016/j.jamcollsurg.2019.09.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Revised: 09/12/2019] [Accepted: 09/12/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND For medically refractory diabetic or idiopathic gastroparesis, gastric electrical stimulation (GES) is an excellent option for symptom control; however, a small subset of patients may develop recurrent or persistent symptoms. Per-oral pyloromyotomy (POP, also described by some authors as gastric per-oral endoscopic myotomy or G-POEM) is an emerging therapy for medically refractory gastroparesis. This study investigated the safety and feasibility of POP after previous GES for recurrent or persistent gastroparesis. STUDY DESIGN We retrospectively identified all patients undergoing POP between January 2016 and December 2017, with GES in situ. Patient characteristics, gastroparesis etiology, and procedural data were collected. Symptoms were assessed with the Gastroparesis Cardinal Symptom Index (GCSI) both before and 30 to 90 days after POP. Standard pre- and post-procedure 4-hour gastric emptying tests were obtained when available. RESULTS There were 22 patients who met inclusion criteria (81.8% female, mean age 42.3 ± 12.4 years). Causes of gastroparesis were diabetes in 38.1%, and idiopathic in 61.9%. The average time since GES insertion was 3.45 years. Mean preoperative 4-hour gastric retention was 50.1%. Most POP procedures were performed in the operating room (90.9%), with mean operative time of 40 minutes and a 1.4-day length of stay. There were 4 readmissions within 30 days, but no POP-related complications. Overall, GCSI improved by an absolute reduction of 1.63 points (p = 0.002), with significant improvements in all sub-scores. Of 11 patients with post-procedural motility or emptying studies available, 7 were normal. CONCLUSIONS Per-oral pyloromyotomy appears to be safe and feasible for patients with recurrent gastroparesis symptoms after GES. Both symptoms and motility significantly improved in the short-term. These data replicate similar data suggesting laparoscopic pyloroplasty as an effective augmentative therapy after GES, but may provide a less invasive option for patients.
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Clinical efficacy of gastric per-oral endoscopic myotomy (G-POEM) in the treatment of refractory gastroparesis and predictors of outcomes: a systematic review and meta-analysis using surgical pyloroplasty as a comparator group. Surg Endosc 2019; 34:3352-3367. [PMID: 31583465 DOI: 10.1007/s00464-019-07135-9] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 09/17/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND AIMS Gastric peroral endoscopic myotomy (G-POEM) is a novel minimally invasive technique in endosurgery. Data is limited as to its efficacy, safety, and predictive factors. We conducted this meta-analysis to evaluate the clinical outcomes of G-POEM and used the outcomes of surgical pyloroplasty as a comparator group in the treatment of refractory gastroparesis. METHODS We searched multiple databases from inception through March 2019 to identify studies that reported on G-POEM and pyloroplasty in gastroparesis. Our primary outcome was to analyze and compare the pooled rates of clinical success, in terms of Gastroparesis Cardinal Symptom Index (GCSI) score and 4-h gastric emptying study (GES) results, with G-POEM and pyloroplasty. RESULTS Three hundred and thirty-two and 375 patients underwent G-POEM (11 studies) and surgical pyloroplasty (seven studies), respectively. The pooled rate of clinical success, based on the GCSI score, with G-POEM was 75.8% (95% CI 68.1-82.1, I2 = 50) and with surgical pyloroplasty was 77.3% (95% CI 66.4-85.4, I2 = 0), with no significance, p = 0.81. The pooled rate of clinical success, based on the 4-hour GES results, with G-POEM was 85.1% (95% CI 68.9-93.7, I2 = 74) and with surgical pyloroplasty was 84% (95% CI 64.4-93.8, I2 = 81), with no significance, p = 0.91. The overall adverse events were comparable. Based on meta-regression analysis, idiopathic gastroparesis, prior treatment with botulinum toxin and gastric stimulator seemed to predict clinical success with G-POEM. CONCLUSION G-POEM demonstrates clinical success in treating refractory gastroparesis. Idiopathic gastroparesis, prior treatment with botulinum injections and gastric stimulator appear to have positive predictive effects on the 4-h GES results after G-POEM. Outcomes seem comparable to surgical pyloroplasty.
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Enhanced recovery outcomes following per-oral pyloromyotomy (POP): a comparison of safety and cost with same-day discharge versus inpatient recovery. Surg Endosc 2019; 34:3153-3162. [DOI: 10.1007/s00464-019-07085-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 08/21/2019] [Indexed: 12/16/2022]
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Abstract
PURPOSE OF REVIEW Peroral endoscopic myotomy (POEM) and gastric peroral endoscopic myotomy (G-POEM) are minimally invasive endoscopic procedures for the treatment of esophageal motility disorders and refractory gastroparesis, respectively. In this review, we highlight the most recent publications on the technical aspects of POEM and G-POEM. RECENT FINDINGS POEM has evolved into a standard therapeutic option in patients with all achalasia subtypes with excellent durability and safety profile. G-POEM is a novel endoscopic procedure with promising results in terms of efficacy, safety, and symptom improvement in patients with refractory gastroparesis. SUMMARY POEM and G-POEM are novel endoscopic procedures. Practice patterns vary among endoscopists and procedure techniques continue to evolve. Comparative studies examining outcomes of different techniques are needed.
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Podboy A, Hwang JH. Technical review of gastric per-oral endoscopic myotomy. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2019. [DOI: 10.18528/ijgii190008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Alexander Podboy
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City, CA, USA
| | - Joo Ha Hwang
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City, CA, USA
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Gastrectomy versus stomach left in situ with Roux-en-Y reconstruction for the treatment of gastroparesis. Surg Endosc 2019; 34:1847-1855. [PMID: 31297624 DOI: 10.1007/s00464-019-06951-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 06/26/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Gastroparesis is a debilitating functional disorder of the stomach marked by delayed gastric emptying in the absence of mechanical obstruction. Patients with severe, refractory symptoms may ultimately be managed with Roux-en-Y reconstruction; however, it is unclear whether the stomach should be left in situ, similar to a conventional gastric bypass, or resected as in gastrectomy. METHODS All patients undergoing Roux-en-Y for the treatment of gastroparesis (GP) at our institution from September 2010 through March 2018 were retrospectively reviewed. Patients with prior gastric resection or whose primary operative indication was not gastroparesis were excluded from analysis. RESULTS Twenty-six patients underwent Roux-en-Y with stomach left in situ (RY-SIS) and twenty-seven patients underwent gastrectomy with Roux-en-Y reconstruction during the study period. The mean age was 49.7 years in the RY-SIS cohort and 48.5 years in the gastrectomy cohort. Etiology of GP was similar between the two cohorts. Patients undergoing gastrectomy were more likely to have previous interventions for GP (63.0% vs. 26.9%). RY-SIS was associated with a shorter operative time (155 vs. 223 min), less blood loss (24 vs. 130 mL), and shorter length of stay (4.0 vs. 7.2 days). Twelve patients (44.4%) had complications within 30 days following gastrectomy compared to two patients (7.7%) following RY-SIS (p = 0.001). Patients in the RY-SIS cohort were more likely to require further subsequent surgical intervention for GP (23.1% vs. 3.7%, p = 0.04). At last follow-up, there were no differences in reported GP symptoms or symptom scoring. CONCLUSIONS Gastrectomy was associated with greater perioperative morbidity compared to leaving the stomach in situ. Symptomatic improvement at intermediate follow-up was equivalent following either procedure. However, patients undergoing RY-SIS were more likely to require subsequent surgical intervention, suggesting that gastrectomy may be a more definitive operation for the management of medically refractory gastroparesis.
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Presidential Forum. Ann Surg 2019; 270:573-584. [PMID: 31274654 DOI: 10.1097/sla.0000000000003421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Podboy A, Hwang JH, Nguyen LA, Garcia P, Zikos TA, Kamal A, Triadafilopoulos G, Clarke JO. Gastric per-oral endoscopic myotomy: Current status and future directions. World J Gastroenterol 2019; 25:2581-2590. [PMID: 31210711 PMCID: PMC6558440 DOI: 10.3748/wjg.v25.i21.2581] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 04/25/2019] [Accepted: 04/29/2019] [Indexed: 02/06/2023] Open
Abstract
Gastroparesis, or symptomatic delayed gastric emptying in the absence of mechanical obstruction, is a challenging and increasingly identified syndrome. Medical options are limited and the only medication approved by the Food and Drug Administration for treatment of gastroparesis is metoclopramide, although other agents are frequently used off label. With this caveat, first-line treatments for gastroparesis include dietary modifications, antiemetics and promotility agents, although these therapies are limited by suboptimal efficacy and significant medication side effects. Treatment of patients that fail first-line treatments represents a significant therapeutic challenge. Recent advances in endoscopic techniques have led to the development of a promising novel endoscopic therapy for gastroparesis via endoscopic pyloromyotomy, also referred to as gastric per-oral endoscopic myotomy or per-oral endoscopic pyloromyotomy. The aim of this article is to review the technical aspects of the per-oral endoscopic myotomy procedure for the treatment of gastroparesis, provide an overview of the currently published literature, and outline potential next directions for the field.
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Affiliation(s)
- Alexander Podboy
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City, CA 94063, United States
| | - Joo Ha Hwang
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City, CA 94063, United States
| | - Linda A Nguyen
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City, CA 94063, United States
| | - Patricia Garcia
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City, CA 94063, United States
| | - Thomas A Zikos
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City, CA 94063, United States
| | - Afrin Kamal
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City, CA 94063, United States
| | - George Triadafilopoulos
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City, CA 94063, United States
| | - John O Clarke
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City, CA 94063, United States
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Strong AT, Landreneau JP, Cline M, Kroh MD, Rodriguez JH, Ponsky JL, El-Hayek K. Per-Oral Pyloromyotomy (POP) for Medically Refractory Post-Surgical Gastroparesis. J Gastrointest Surg 2019; 23:1095-1103. [PMID: 30809781 DOI: 10.1007/s11605-018-04088-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 12/16/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND Post-surgical gastroparesis (psGP) is putatively related to vagal denervation from either therapeutic transection or inadvertent injury. Here, we present a series of patients undergoing endoscopic per-oral pyloromyotomy (POP) as a treatment for medically refractory psGP. METHODS Patients identified from a prospectively maintained database of patients undergoing POP procedures at our institution from January 2016 to January 2018 were included. Surgical history, symptom scores, and gastric emptying studies before and 3 months after POP were additionally recorded. RESULTS During the study period, 177 POP procedures were performed, of which 38 (21.5%) were for psGP. The study cohort was 84.2% female with a mean body mass index of 27.6 kg/m2 and mean age of 55.2 years. Common comorbidities included hypertension (34.2%), depression (31.6%), and gastroesophageal reflux disease (28.9%). Hiatal/paraesophageal hernia repair (39.5%) or fundoplication (36.8%) preceded psGP diagnosis most often. The mean operative time was 30 ± 20 min. There were no intraoperative complications. Mean postoperative length of stay was 1.2 days. There were two readmissions within 30 days, one for melena and one for dehydration. The mean improvement in total Gastroparesis Symptom Index Score was 1.29 (p = 0.0002). The mean 4-h gastric retention improved from a pre-POP mean of 46.4 to 17.9% post-POP. Normal gastric emptying was noted in 50% of subjects with available follow-up imaging. CONCLUSION POP is a safe and effective endoscopic therapy for patients with psGP. POP should be considered a reasonable first-line option for patients with medically refractory psGP and may allow stomach preservation.
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Affiliation(s)
- Andrew T Strong
- Department of General Surgery, Cleveland Clinic, Desk A-100, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Joshua P Landreneau
- Department of General Surgery, Cleveland Clinic, Desk A-100, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Michael Cline
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA.,Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | - Matthew D Kroh
- Department of General Surgery, Cleveland Clinic, Desk A-100, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA.,Digestive Disease Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - John H Rodriguez
- Department of General Surgery, Cleveland Clinic, Desk A-100, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Jeffrey L Ponsky
- Department of General Surgery, Cleveland Clinic, Desk A-100, 9500 Euclid Avenue, Cleveland, OH, 44195, USA.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
| | - Kevin El-Hayek
- Department of General Surgery, Cleveland Clinic, Desk A-100, 9500 Euclid Avenue, Cleveland, OH, 44195, USA. .,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA.
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Bekkelund M, Sangnes DA, Gunnar Hatlebakk J, Aabakken L. Pathophysiology of idiopathic gastroparesis and implications for therapy. Scand J Gastroenterol 2019; 54:8-17. [PMID: 30638082 DOI: 10.1080/00365521.2018.1558280] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Idiopathic gastroparesis is a gastric motility disorder characterized by chronic upper gastrointestinal symptoms and delayed gastric emptying without an identifiable underlying condition. This review summarizes recent understanding of the pathophysiology and treatment of idiopathic gastroparesis. MATERIALS AND METHODS Structured literature search in the PubMed, Embase and ClinicalTrials.gov databases. RESULTS Idiopathic gastroparesis involves several alterations in gastric motility and sensation, including delayed gastric emptying, altered myoelectrical activity, impaired fundic accommodation, visceral hypersensitivity and disturbances in antropyloroduodenal motility and coordination. Multiple cellular changes have been identified, including depletion of interstitial cells of Cajal (ICC) and enteric nerves, as well as stromal fibrosis. The underlying cause of these changes is not fully understood but may be an immune imbalance, including loss of anti-inflammatory heme-oxygenase-1 positive (HO-1) macrophages. There is currently no causal therapy for idiopathic gastroparesis. The treatment ladder consists of dietary measures, prokinetic and antiemetic medications, and varying surgical or endoscopic interventions, including promising pyloric therapies. There are ongoing trials with several novel medications, raising hopes for future treatment. CONCLUSIONS Patients with idiopathic gastroparesis present several pathophysiological alterations in the stomach, where depletion of ICC is of special importance. Treatment is currently focused on alleviating symptoms through dietary adjustments, medication or surgical or endoscopic interventions.
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Affiliation(s)
- Mattis Bekkelund
- a Faculty of Medicine, Department of Clinical Medicine , University of Oslo , Oslo , Norway.,b Department of Medicine , National Centre for Functional Gastrointestinal Disorders, Haukeland University Hospital , Bergen , Norway
| | - Dag A Sangnes
- b Department of Medicine , National Centre for Functional Gastrointestinal Disorders, Haukeland University Hospital , Bergen , Norway.,c Department of Medicine , Haukeland University Hospital , Bergen , Norway.,d Clinical institute 1, University of Bergen , Bergen , Norway
| | - Jan Gunnar Hatlebakk
- b Department of Medicine , National Centre for Functional Gastrointestinal Disorders, Haukeland University Hospital , Bergen , Norway.,c Department of Medicine , Haukeland University Hospital , Bergen , Norway.,d Clinical institute 1, University of Bergen , Bergen , Norway
| | - Lars Aabakken
- a Faculty of Medicine, Department of Clinical Medicine , University of Oslo , Oslo , Norway.,e Department of Transplantation Medicine , Section for Gastroenterology, Oslo University Hospital , Oslo , Norway
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