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Na HK, Li AA, Gottfried-Blackmore A, Podboy AJ, Esquivel MM, Joseph AA, Nguyen L, Hwang JH. Pyloric Dysfunction: A Review of the Mechanisms, Diagnosis, and Treatment. Gut Liver 2025; 19:327-345. [PMID: 40058793 PMCID: PMC12070220 DOI: 10.5009/gnl240421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2024] [Revised: 11/04/2024] [Accepted: 11/06/2024] [Indexed: 05/14/2025] Open
Abstract
Pyloric dysfunction is defined as hypertonia or spasm of the pyloric sphincter. The pylorus plays a key role in gastric emptying, but its function remains incompletely understood. Most studies have focused on gastroparesis regardless of the underlying pathophysiology. Few studies have reported pyloric dysfunction in patients with gastroparesis, and the diagnostic and treatment modalities for pyloric dysfunction are not well established. Recently developed diagnostic modalities assessing pyloric function, such as high-resolution antroduodenal manometry and endoluminal functional lumen imaging, are currently being evaluated. A variety of therapeutic interventions targeting the pylorus, including pharmacologic agents, intrapyloric botulinum injection, endoscopic balloon dilation, stent insertion, surgical pyloroplasty, and gastric peroral endoscopic pyloromyotomy, have been proposed. Among these, gastric peroral endoscopic pyloromyotomy has emerged as a novel, minimally invasive therapy with demonstrated efficacy and safety for refractory gastroparesis. This article reviews the pathophysiology of pyloric dysfunction and the potential diagnostic and therapeutic modalities based on the latest literature.
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Affiliation(s)
- Hee Kyong Na
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Andrew A. Li
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Andres Gottfried-Blackmore
- Department of Pharmacology and Division of Gastroenterology, Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Alexander J. Podboy
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, VA, USA
| | - Micaela M. Esquivel
- Division of General Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Abel A. Joseph
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Linda Nguyen
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Joo Ha Hwang
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Division of General Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
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Eriksson SE, Chrysostome ML, Sarici IS, Nguyen J, Zheng P, Ayazi S. Pyloric drainage interventions for gastroparesis: a comparison of laparoscopic pyloroplasty and gastric peroral endoscopic myotomy (G-POEM) outcomes. Surg Endosc 2025:10.1007/s00464-025-11731-3. [PMID: 40251315 DOI: 10.1007/s00464-025-11731-3] [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: 10/15/2024] [Accepted: 04/06/2025] [Indexed: 04/20/2025]
Abstract
BACKGROUND The endoscopic approach to the surgical management of gastroparesis is gaining popularity. However, data comparing endoscopic myotomy to traditional laparoscopic pyloroplasty are limited. This study aimed to compare outcomes between gastric-per-oral endoscopic myotomy (G-POEM) and pyloroplasty. METHODS Gastroparesis patients who underwent pyloroplasty or G-POEM from 2013 through 2023 at our institution were reviewed. Pre/postoperative gastroparesis cardinal symptom index (GCSI), resolution of the predominant gastroparesis symptom, and gastric emptying scintigraphy (GES) were assessed. RESULTS There were 314 patients who underwent surgical myotomy. Median (IQR) age was 51.9 (40-62) and 84.1% were female. Of these 81 underwent G-POEM and 233 underwent pyloroplasty. Age and sex were similar between surgical approaches (p > 0.05). Gastroparesis etiology was 61.8% idiopathic, 21.3% diabetic, and 16.9% postsurgical. Postsurgical etiology was more likely to undergo G-POEM (25.9% vs. 13.7%, p = 0.046). At a mean (SD) of 14.2(17) months resolution of the predominant gastroparesis symptom was achieved by 70.0% after G-POEM and 76.4% after pyloroplasty (p = 0.297). The GCSI improved after G-POEM [3.1(2-4) to 2.4 (2-3), p = 0.0498] and pyloroplasty [3.1(3-4) to 2.4(2-3), p < 0.0001]. There was no difference in postoperative GCSI (p = 0.805) or percent GCSI improvement (p = 0.976) between groups. In the 96 patients with pre- and postoperative GES, 4 h retention decreased for pyloroplasty from 29.0% (18-43) to 4.2% (1.0-18) (p < 0.0001) and for G-POEM from 23.0 (13-49) to 13 (5.0-29), (p = 0.045). Pyloroplasty showed a trend towards better emptying (p = 0.0719) with more patients achieving ≥ 50% improvement (70.3% vs. 50%, p = 0.086). CONCLUSIONS Gastroparesis symptom improvement was similar after pyloroplasty and G-POEM; however, there was a trend towards better improvement in gastric emptying after pyloroplasty.
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Affiliation(s)
- Sven E Eriksson
- Foregut Division, Surgical Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 454, Pittsburgh, PA, 15224, USA
- Chevalier Jackson Esophageal Research Center, Western Pennsylvania Hospital, Pittsburgh, PA, USA
| | - Marie-Lise Chrysostome
- Foregut Division, Surgical Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 454, Pittsburgh, PA, 15224, USA
| | - Inanc S Sarici
- Foregut Division, Surgical Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 454, Pittsburgh, PA, 15224, USA
- Chevalier Jackson Esophageal Research Center, Western Pennsylvania Hospital, Pittsburgh, PA, USA
| | - Johnathan Nguyen
- Foregut Division, Surgical Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 454, Pittsburgh, PA, 15224, USA
| | - Ping Zheng
- Foregut Division, Surgical Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 454, Pittsburgh, PA, 15224, USA
| | - Shahin Ayazi
- Foregut Division, Surgical Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 454, Pittsburgh, PA, 15224, USA.
- Chevalier Jackson Esophageal Research Center, Western Pennsylvania Hospital, Pittsburgh, PA, USA.
- Department of Surgery, Drexel University, Philadelphia, PA, USA.
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Shargo R, Poonen-Honig I, Thélin C, DuCoin CG, Mhaskar R, Docimo S, Sujka JA. Dumping Syndrome and Bile Acid Reflux Following Pyloroplasty and Gastric Peroral Endoscopic Myotomy (G-POEM) for Refractory Gastroparesis: A Systematic Review. Cureus 2025; 17:e79056. [PMID: 40104464 PMCID: PMC11914853 DOI: 10.7759/cureus.79056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2025] [Indexed: 03/20/2025] Open
Abstract
Treatment options for medication- and diet-resistant gastroparesis include drainage procedures such as pyloroplasty and gastric peroral endoscopic myotomy (G-POEM). While dumping syndrome (DS) and bile acid gastritis (BAG) have been documented as complications following pyloric drainage procedures, limited evidence exists concerning their incidence after pyloroplasty and G-POEM for refractory gastroparesis. We performed a systematic review of outcomes following pyloroplasty and G-POEM for refractory gastroparesis (PROSPERO: CRD42024559654). PubMed, Embase, Cochrane, and Web of Science databases were systematically searched for articles reporting rates of DS and BAG following pyloric drainage procedures. Assessed outcomes included rates of DS and BAG. Results were narratively synthesized and presented descriptively. Of the 2278 records reviewed, 10 studies were included. Six studies evaluated pyloroplasty, and four studies evaluated G-POEM. Nine studies reported incidence of DS, and two studies reported rates of BAG. The incidence of DS ranged from 0% to 23.1%, with a median incidence of 3.23% and an interquartile range of 6.95% among nine studies. The incidence of BAG ranged from 0% to 15.4% in two studies. The studies displayed high heterogeneity in study design, patient population, and co-interventions, precluding collective data analysis and limiting generalizability. All studies displayed a moderate to serious risk of bias. There exists a paucity of data regarding the incidence of DS and BAG following pyloroplasty and G-POEM for refractory gastroparesis. Despite the theoretical association of these complications with pylorus-modifying procedures, our findings suggest that they may be uncommon or underreported in the treatment of refractory gastroparesis. Improved reporting of these outcomes and robust prospective studies investigating the incidence of such complications are required.
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Affiliation(s)
- Ryan Shargo
- Department of Medical Education, University of South Florida Morsani College of Medicine, Tampa, USA
| | - Isaac Poonen-Honig
- Department of Medical Education, University of South Florida Morsani College of Medicine, Tampa, USA
| | - Camille Thélin
- Department of Gastroenterology, University of South Florida Morsani College of Medicine, Tampa, USA
| | - Christopher G DuCoin
- Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, USA
| | - Rahul Mhaskar
- Department of Medical Education, University of South Florida Morsani College of Medicine, Tampa, USA
| | - Salvatore Docimo
- Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, USA
| | - Joseph A Sujka
- Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, USA
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Kim HKJ, DeCicco J, Prasad R, Alkhatib H, El-Hayek K. Pyloric impedance planimetry during endoscopic per-oral pyloromyotomy guides myotomy extent. J Gastrointest Surg 2025; 29:101856. [PMID: 39419276 DOI: 10.1016/j.gassur.2024.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2024] [Revised: 09/26/2024] [Accepted: 10/10/2024] [Indexed: 10/19/2024]
Abstract
BACKGROUND Per-oral pyloromyotomy (POP), also known as gastric per-oral endoscopic myotomy, is the first-line endoscopic intervention for medically refractory gastroparesis. This study aimed to assess the value of pyloric impedance planimetry using a functional lumen imaging probe (FLIP) during POP. METHODS Patients who underwent POP between October 2019 and February 2024 were retrospectively reviewed. FLIP measurements, symptoms measured using the Gastroparesis Cardinal Symptom Index (GCSI), and gastric emptying scintigraphy (GES) were evaluated before and after POP. RESULTS Of 35 patients who underwent POP, 29 (82.9%) were female, the median age was 51.3 years (IQR, 38.4-60.9), and the median body mass index was 29.26 kg/m2 (IQR, 25.46-32.56). In addition, 23 patients had pre- and post-POP FLIP measurements. The median pyloric diameter increased from 14.4 (IQR, 12.0-16.0) to 16.0 (IQR, 14.8-18.0) mm (S = 116.5; P < .0001). The median distensibility index increased from 4.85 (IQR, 3.38-6.00) to 8.45 (IQR, 5.25-11.00) mm2/mm Hg (S = 112; P < .0001). The management changed based on FLIP values for 5 patients (21.7%), prompting additional myotomy. At 18.0 days (IQR, 12.8-47.8) after the procedure, the median GCSI score decreased from 3.33 (IQR, 2.56-4.12) preoperatively to 2.00 (IQR, 1.00-2.89) postoperatively (S = -193; P < .001). At a median follow-up of 136 days (IQR, 114-277), improvement in GCSI score persisted, with a median score of 2.44 (IQR, 1.44-3.67) (S = -61; P = .021). The median retention at 4 hours on GES decreased from 29.0% (IQR, 16.5-52.0%) to 19.5% (IQR, 5.75-35.30%) at 97 days (IQR, 88-130) after the procedure (S = -108; P = .0038). There was a 75% improvement and a 40% normalization in objective gastric emptying (n = 26). A greater increase in diameter after pyloromyotomy was associated with a greater decrease in 4-hour gastric retention (r = -0.4886; P = .021). CONCLUSION POP with FLIP resulted in clinical and radiographic improvements in patients with gastroparesis. FLIP measurements guided myotomy extent, changing the management in 21.7% of patients, and were associated with gastric emptying, demonstrating its distinct utility in the treatment of gastroparesis.
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Affiliation(s)
- Hee Kyung Jenny Kim
- Case Western Reserve University School of Medicine, Cleveland, OH, United States; Division of General Surgery, Department of Surgery, The MetroHealth System, Cleveland, OH, United States.
| | - Jamie DeCicco
- Division of General Surgery, Department of Surgery, The MetroHealth System, Cleveland, OH, United States; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, United States
| | - Rachna Prasad
- Division of General Surgery, Department of Surgery, The MetroHealth System, Cleveland, OH, United States; Northeast Ohio Medical University, Rootstown, OH, United States
| | - Hemasat Alkhatib
- Case Western Reserve University School of Medicine, Cleveland, OH, United States; Division of General Surgery, Department of Surgery, The MetroHealth System, Cleveland, OH, United States
| | - Kevin El-Hayek
- Case Western Reserve University School of Medicine, Cleveland, OH, United States; Division of General Surgery, Department of Surgery, The MetroHealth System, Cleveland, OH, United States
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Tan J, Wu H, Yang X, Yang Y, Zhang L, Wang P, Shi J, Lu Y, Gao Q, Shi R. A long-term follow-up study of gastric peroral endoscopic myotomy (G-POEM) in a large cohort of patients with postsurgical gastroparesis. Surg Endosc 2024; 38:7416-7425. [PMID: 39448403 PMCID: PMC11614976 DOI: 10.1007/s00464-024-11184-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2024] [Accepted: 08/10/2024] [Indexed: 10/26/2024]
Abstract
INTRODUCTION Postoperative gastroparesis occurs after surgeries which affect the upper digestive tract. Gastric peroral endoscopic myotomy (G-POEM) is a treatment for postoperative gastroparesis. The present study boasts the long-term efficacy and safety of G-POEM in a large cohort of patients. PATIENTS AND METHODS Gastroparesis Cardinal Symptom Index (GCSI) and Gastroesophageal Reflux Disease Questionnaire (GERDQ) were utilized for the assessment of postsurgical gastroparesis symptoms. Gastroscope was used to observe the anastomotic site. Three-dimensional ultrasound was used to measure the morphological structure of the gastric antrum and pylorus tube. Gastric emptying time was calculated by analyzing the volume change of gastric antrum. RESULTS Significant clinical effectiveness of G-POEM was observed. The GCSI score, including each subscale score, showed significant decrease after G-POEM. Before G-POEM, there was a negative correlation between GCSI score and the inner diameter of pylorus, as well as a positive correlation with the length of pyloric tube. The similar results were found in the scores of nausea/vomiting and postprandial fullness/early satiety subscales. No correlation was observed between GCSI score and the emptying time, nor between the emptying time and the parameters of antrum morphology. After G-POEM, no correlation was found between GCSI (including subscales) score, the emptying time, and the parameters of antrum morphology. Patients who exhibited as clinical non-responders often accompanied with GERD symptoms. After G-POEM, the score of GERDQ decreased significantly. Either before or after G-POEM, no correlation was noticed between GERDQ scores, the emptying time and the parameters of antrum morphology. CONCLUSION The technique of G-POEM was demonstrated as a minimally invasive approach with the long-term efficacy and safety in therapying postoperative gastroparesis.
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Affiliation(s)
- Jiacheng Tan
- Department of Gastroenterology, Zhongda Hospital Southeast University, No. 87 Dingjiaqiao, Nanjing, 210009, Jiangsu, China
| | - Hailu Wu
- Department of Gastroenterology, Zhongda Hospital Southeast University, No. 87 Dingjiaqiao, Nanjing, 210009, Jiangsu, China
| | - Xinyi Yang
- Department of Gastroenterology, Zhongda Hospital Southeast University, No. 87 Dingjiaqiao, Nanjing, 210009, Jiangsu, China
| | - Yuling Yang
- Department of Gastroenterology, Zhongda Hospital Southeast University, No. 87 Dingjiaqiao, Nanjing, 210009, Jiangsu, China
| | - Ling Zhang
- Department of Gastroenterology, Zhongda Hospital Southeast University, No. 87 Dingjiaqiao, Nanjing, 210009, Jiangsu, China
| | - Panpan Wang
- Department of Gastroenterology, Zhongda Hospital Southeast University, No. 87 Dingjiaqiao, Nanjing, 210009, Jiangsu, China
| | - Jinjun Shi
- Department of Ultrasound, Zhongda Hospital Southeast University, Nanjing, 210009, Jiangsu, China
| | - Yanjia Lu
- Department of Ultrasound, Zhongda Hospital Southeast University, Nanjing, 210009, Jiangsu, China
| | - Qi Gao
- Department of Ultrasound, Zhongda Hospital Southeast University, Nanjing, 210009, Jiangsu, China
| | - Ruihua Shi
- Department of Gastroenterology, Zhongda Hospital Southeast University, No. 87 Dingjiaqiao, Nanjing, 210009, Jiangsu, China.
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Eriksson SE, Gardner M, Sarici IS, Zheng P, Chaudhry N, Jobe BA, Ayazi S. Efficacy of gastric stimulator as an adjunct to pyloroplasty for gastroparesis: characterizing patients suitable for single procedure vs dual procedure approach. J Gastrointest Surg 2024; 28:1769-1776. [PMID: 39127405 DOI: 10.1016/j.gassur.2024.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2024] [Revised: 07/29/2024] [Accepted: 08/05/2024] [Indexed: 08/12/2024]
Abstract
BACKGROUND Pyloroplasty is an effective surgery for gastroparesis. However, some patients fail to improve after pyloric drainage and may require subsequent gastric electric stimulation. There is a paucity of data on the efficacy of gastric stimulator as an adjunct to failed pyloroplasty. This study aimed to describe our experience with pyloroplasty, determine the efficacy of gastric stimulator for failed pyloroplasty, and compare the final outcomes of those who required pyloroplasty with and without gastric stimulator for gastroparesis. METHODS Records of patients who underwent primary pyloroplasty for gastroparesis at our institution were reviewed. Patients with poor symptomatic improvement after pyloroplasty underwent subsequent gastric stimulator. Symptoms were assessed using the gastroparesis cardinal symptom index (GCSI) preoperatively and after each surgery. Severe gastroparesis was defined as GCSI total score ≥3. Outcomes were assessed after pyloroplasty in all patients and after stimulator in patients who failed pyloroplasty. Final outcomes were then compared between those who did and did not require adjunct gastric stimulator. RESULTS The study population consisted of 104 patients (89.4% females) with a mean (SD) age of 42.2 years (11) and body mass index of 26.9 kg/m2 (7). Gastroparesis etiologies were 71.2% idiopathic, 17.3% diabetic, and 11.5% postsurgical. At 18.7 months (12) after pyloroplasty, there was a decrease in the GCSI total score (3.5 [1] to 2.7 [1.2]; P = .0012) and the rate of severe gastroparesis (71.9%-29.3%; P < .0001). Gastric emptying scintigraphy (GES) 4-hour retention decreased (36.5 [24] to 15.3 [18]; P = .0003). Adjunct gastric stimulator was required by 30 patients (28.8%) owing to suboptimal outcomes with no improvement in GCSI (P = .201) or GES (P = .320). These patients were younger (40.5 [10.6] vs 49.6 [15.2] years; P = .0016), with higher baseline GCSI total scores (4.3 [0.7] vs 3.7 [1.1]; P < .001) and more severe gastroparesis (100% vs 55.6%; P < .001). All other preoperative characteristics were similar. At 21.7 months (15) after gastric stimulator, there was improvement in GCSI (4.1 [0.7] to 2.6 [1.1]; P < .0001), severe gastroparesis (100%-33.3%; P < .0001), and GES 4-hour retention (21.2 [22] to 7.6 [10]; P = .054). Before gastric stimulator, those who failed pyloroplasty had significantly worse GCSI (P = .0009) and GES (P = .048). However, after gastric stimulator, GCSI and GES improved and were comparable with those who only required pyloroplasty (P > .05). CONCLUSION Pyloroplasty improved gastroparesis symptoms and gastric emptying, yet 28% failed, requiring gastric stimulator. Younger patients and those with preoperative GCSI scores ≥3 were more likely to fail. Gastric stimulator improved outcomes after failed pyloroplasty, with comparable final GCSI and GES with those who did not fail.
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Affiliation(s)
- Sven E Eriksson
- Foregut Division, Surgical Institute, Allegheny Health Network, Pittsburgh, PA, United States; Chevalier Jackson Research Foundation, Esophageal Institute, Western Pennsylvania Hospital, Pittsburgh, PA, United States
| | - Margaret Gardner
- Foregut Division, Surgical Institute, Allegheny Health Network, Pittsburgh, PA, United States
| | - Inanc S Sarici
- Foregut Division, Surgical Institute, Allegheny Health Network, Pittsburgh, PA, United States; Chevalier Jackson Research Foundation, Esophageal Institute, Western Pennsylvania Hospital, Pittsburgh, PA, United States
| | - Ping Zheng
- Foregut Division, Surgical Institute, Allegheny Health Network, Pittsburgh, PA, United States
| | - Naveed Chaudhry
- Foregut Division, Surgical Institute, Allegheny Health Network, Pittsburgh, PA, United States
| | - Blair A Jobe
- Foregut Division, Surgical Institute, Allegheny Health Network, Pittsburgh, PA, United States; Chevalier Jackson Research Foundation, Esophageal Institute, Western Pennsylvania Hospital, Pittsburgh, PA, United States; Department of Surgery, Drexel University, Philadelphia, PA, United States
| | - Shahin Ayazi
- Foregut Division, Surgical Institute, Allegheny Health Network, Pittsburgh, PA, United States; Chevalier Jackson Research Foundation, Esophageal Institute, Western Pennsylvania Hospital, Pittsburgh, PA, United States; Department of Surgery, Drexel University, Philadelphia, PA, United States.
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Aeschbacher P, Garcia A, Dourado J, Rogers P, Zoe G, Pena A, Szomstein S, Menzo EL, Rosenthal R. Outcome of gastric electrical stimulator with and without pyloromyotomy for refractory gastroparesis. Surg Endosc 2024; 38:6026-6032. [PMID: 39110219 PMCID: PMC11458628 DOI: 10.1007/s00464-024-11099-w] [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: 04/19/2024] [Accepted: 07/15/2024] [Indexed: 10/08/2024]
Abstract
BACKGROUND Surgical treatments of refractory gastroparesis include pyloromyotomy and gastric electrical stimulator (GES). It is unclear if patients may benefit from a combined approach with concomitant GES and pyloromyotomy. METHODS Retrospective cohort analysis of all patients with refractory gastroparesis treated with GES implantation with and without concomitant pyloromyotomy at Cleveland Clinic Florida from January 2003 to January 2023. Primary endpoint was efficacy (clinical response duration and success rate) and secondary endpoints included safety (postoperative morbidity) and length of stay. Success rate was defined as the absence of one of the following reinterventions during follow-up: Roux-en-Y gastric bypass (RYGB), pyloromyotomy, GES removal. RESULTS During a period of 20 years, 134 patients were treated with GES implantation. Three patients with history of previous surgical pyloromyotomy or RYGB were excluded from the analysis. Median follow-up was 31 months (IQR 10, 72). Forty patients (30.5%) had GES with pyloromyotomy, whereas 91 (69.5%) did not have pyloromyotomy. Most of the patients had idiopathic (n = 68, 51.9%) or diabetic (n = 58, 43.3%) gastroparesis. Except for preoperative use of opioids (47.5 vs 14.3%; p < 0.001), patient's characteristics were similar in both groups. There were no significant differences between the two groups in terms of overall postoperative complications (17.5% vs 14.3%; p = 0.610), major postoperative complications (0% vs 2.2%; p = 1), and length of stay (2(IQR 1, 2) vs 2(IQR 1, 3) days; p = 0.068). At 5 years, success rate was higher in patients with than without pyloromyotomy however not statistically significant (82% versus 62%, p = 0.066). Especially patients with diabetic gastroparesis seemed to benefit from pyloromyotomy during GES (100% versus 67%, p = 0.053). In an adjusted Cox regression, GES implantation without pyloromyotomy was associated with a 2.66 times higher risk of treatment failure compared to GES implantation with pyloromyotomy (HR 2.66, 95% CI 1.03-6.94, p = 0.044). CONCLUSION Pyloromyotomy during GES implantation for gastroparesis seems to be associated with a longer clinical response with similar postoperative morbidity and length of hospital stay than GES without pyloromyotomy. Patient with diabetic gastroparesis might benefit from a combination of GES implantation and pyloromyotomy.
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Affiliation(s)
- Pauline Aeschbacher
- Department of General Surgery and the Bariatric and Metabolic Institute, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Angelica Garcia
- Department of General Surgery and the Bariatric and Metabolic Institute, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA
| | - Justin Dourado
- Ellen Leifer Shulman and Steven Shulman Digestive Diseases Centre, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
| | - Peter Rogers
- Ellen Leifer Shulman and Steven Shulman Digestive Diseases Centre, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
| | - Garoufalia Zoe
- Ellen Leifer Shulman and Steven Shulman Digestive Diseases Centre, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, FL, 33331, USA
| | - Ana Pena
- Department of General Surgery and the Bariatric and Metabolic Institute, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA
| | - Samuel Szomstein
- Department of General Surgery and the Bariatric and Metabolic Institute, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA
| | - Emanuele Lo Menzo
- Department of General Surgery and the Bariatric and Metabolic Institute, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA
| | - Raul Rosenthal
- Department of General Surgery and the Bariatric and Metabolic Institute, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, Weston, FL, 33331, USA.
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Vasatko M, Evinova E, Hugova K, Simkova D, Yepishkina K, Amin S, Martinek J. Endoscopic pyloromyotomy for treatment of gastroparesis: A new standard or still an experimental approach? Best Pract Res Clin Gastroenterol 2024; 71:101910. [PMID: 39209413 DOI: 10.1016/j.bpg.2024.101910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Accepted: 04/03/2024] [Indexed: 09/04/2024]
Abstract
Gastroparesis (GP) can be a severe and debilitating disease. Its pathophysiology is complex and not completely understood. Two principal mechanisms are responsible for the development of symptoms - gastric hypomotility and pylorospasm. Pylorus targeted therapies aim to decrease presumably elevated pyloric tone - pylorospasm. There is a growing body of evidence about their role in the treatment algorithm of GP. G-POEM (endoscopic pyloromyotomy) is an extensively studied pylorus targeted therapy. Its efficacy ranges between 56 and 80% and the number of recurrences among those with treatment effect seems low. G-POEM is a safe procedure with very low frequency of severe adverse events. At present, G-POEM should not be considered as an experimental approach and may be offered to all patients with refractory and severe GP. Nevertheless, G-POEM is not a first line treatment. Conservative measures such as diet modification and pharmacotherapy should always be tried before G-POEM is considered. Further research must focus on better patient selection as at present there are no standardized criteria. Functional imaging such as impedance planimetry (EndoFlip) may hold promise in this regard.
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Affiliation(s)
- Martin Vasatko
- Department of Hepatogastroenterology, Institute of Clinical and Experimental Medicine, Prague, Czech Republic; Institute of Physiology, Charles University in Prague, Prague, Czech Republic
| | - Eva Evinova
- Institute of Physiology, Charles University in Prague, Prague, Czech Republic; Department of Gastroenterology, Vitkovice Hospital, Czech Republic
| | - Kristina Hugova
- Department of Hepatogastroenterology, Institute of Clinical and Experimental Medicine, Prague, Czech Republic; Institute of Physiology, Charles University in Prague, Prague, Czech Republic
| | - Dagmar Simkova
- Department of Hepatogastroenterology, Institute of Clinical and Experimental Medicine, Prague, Czech Republic; Institute of Physiology, Charles University in Prague, Prague, Czech Republic
| | - Katerina Yepishkina
- Department of Hepatogastroenterology, Institute of Clinical and Experimental Medicine, Prague, Czech Republic
| | - Sunil Amin
- Division of Digestive Health and Liver Disease, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Jan Martinek
- Department of Hepatogastroenterology, Institute of Clinical and Experimental Medicine, Prague, Czech Republic; Institute of Physiology, Charles University in Prague, Prague, Czech Republic; Faculty of Medicine, Ostrava University, Ostrava, Czech Republic.
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9
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Restrepo-Rodas G, Barajas-Gamboa JS, Dang JT, Piechowska-Jóźwiak MI, Khan M, Diaz Del Gobbo G, Abdallah M, Moreno C, Abril C, Pantoja JP, Guerron AD, Corcelles R, Kroh M, Rodriguez J. Seven-Year Experience of Intramural Surgery in the Middle East: A Safety and Feasibility Analysis. J Clin Med 2024; 13:3989. [PMID: 38999553 PMCID: PMC11242680 DOI: 10.3390/jcm13133989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Revised: 06/26/2024] [Accepted: 07/04/2024] [Indexed: 07/14/2024] Open
Abstract
Background: Intramural surgery techniques, particularly esophageal peroral endoscopic myotomy (E-POEM), gastric peroral endoscopic myotomy (G-POEM), and peroral endoscopic myotomy for Zenker's (Z-POEM), have emerged as forefront minimally invasive endoscopic procedures. While several studies have reported on the outcomes in North America and Asia, evidence in the Middle East and North Africa remains limited. This study aims to evaluate the feasibility and safety of intramural surgery techniques within this region. Methods: This retrospective cohort study was conducted with approval from the institutional review board. All patients who underwent esophageal peroral endoscopic myotomy, gastric peroral endoscopic myotomy, and peroral endoscopic myotomy for Zenker's from January 2016 to August 2023 were included. Results: In total, 119 patients underwent intramural surgery procedures during this period. The esophageal peroral endoscopic myotomy group had 81 (68%) patients, the gastric peroral endoscopic myotomy had 34 (28.6%) patients, and the peroral endoscopic myotomy for Zenker's had 4 (3.4%) patients. The full cohort was 48.7% female, with a mean overall age of 40.5 years. The mean overall body mass index was 27.5 kg/m2. The chief complaint was dysphagia (n = 80, 67.2%). All cases were successfully completed endoscopically. During the first 30 days, the most common complications were nausea/vomiting requiring admission (n = 4, 4.76%) and pneumomediastinum (n = 2, 2.38%). At a follow-up of 19 months, there were four mortalities; the causes of death were cardiac arrest (three cases) and end-stage prostate cancer (one case). Conclusions: Intramural surgery techniques are safe and technically feasible with low complication rates. Our study suggests that clinical success in the Middle East and Northern Africa population is comparable to larger international series.
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Affiliation(s)
- Gabriela Restrepo-Rodas
- Department of General Surgery, Cleveland Clinic Abu Dhabi, Abu Dhabi 112412, United Arab Emirates
| | - Juan S Barajas-Gamboa
- Department of General Surgery, Cleveland Clinic Abu Dhabi, Abu Dhabi 112412, United Arab Emirates
| | - Jerry T Dang
- Department of General Surgery, Cleveland Clinic, Cleveland, OH 44195, USA
- School of Medicine, Case Western Reserve University, Cleveland, OH 44106, USA
| | | | - Mohammed Khan
- Department of General Surgery, Cleveland Clinic Abu Dhabi, Abu Dhabi 112412, United Arab Emirates
| | - Gabriel Diaz Del Gobbo
- Department of General Surgery, Cleveland Clinic Abu Dhabi, Abu Dhabi 112412, United Arab Emirates
| | - Mohammed Abdallah
- Department of General Surgery, Cleveland Clinic Abu Dhabi, Abu Dhabi 112412, United Arab Emirates
| | - Cristobal Moreno
- Department of General Surgery, Cleveland Clinic Abu Dhabi, Abu Dhabi 112412, United Arab Emirates
| | - Carlos Abril
- Department of General Surgery, Cleveland Clinic Abu Dhabi, Abu Dhabi 112412, United Arab Emirates
- School of Medicine, Case Western Reserve University, Cleveland, OH 44106, USA
| | - Juan Pablo Pantoja
- Department of General Surgery, Cleveland Clinic Abu Dhabi, Abu Dhabi 112412, United Arab Emirates
| | - Alfredo D Guerron
- Department of General Surgery, Cleveland Clinic Abu Dhabi, Abu Dhabi 112412, United Arab Emirates
| | - Ricard Corcelles
- Department of General Surgery, Cleveland Clinic, Cleveland, OH 44195, USA
- School of Medicine, Case Western Reserve University, Cleveland, OH 44106, USA
| | - Matthew Kroh
- Department of General Surgery, Cleveland Clinic, Cleveland, OH 44195, USA
- School of Medicine, Case Western Reserve University, Cleveland, OH 44106, USA
| | - John Rodriguez
- Department of General Surgery, Cleveland Clinic Abu Dhabi, Abu Dhabi 112412, United Arab Emirates
- School of Medicine, Case Western Reserve University, Cleveland, OH 44106, USA
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10
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Chang SY, Jin GH, Sun HB, Yang D, Tang TY. Applications of gastric peroral endoscopic myotomy in the treatment of upper gastrointestinal tract disease. World J Gastrointest Surg 2024; 16:658-669. [PMID: 38577089 PMCID: PMC10989344 DOI: 10.4240/wjgs.v16.i3.658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 01/15/2024] [Accepted: 02/08/2024] [Indexed: 03/22/2024] Open
Abstract
Gastric peroral endoscopic myotomy (G-POME) is an emerging minimally invasive endoscopic technique involving the establishment of a submucosal tunnel around the pyloric sphincter. In 2013, Khashab et al used G-POME for the first time in the treatment of gastroparesis with enhanced therapeutic efficacy, providing a new direction for the treatment of gastroparesis. With the recent and rapid development of G-POME therapy technology, progress has been made in the treatment of gastroparesis and other upper digestive tract diseases, such as congenital hypertrophic pyloric stenosis and gastric sleeve stricture, with G-POME. This article reviews the research progress and future prospects of G-POME for the treatment of upper digestive tract gastrointestinal diseases.
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Affiliation(s)
- Shi-Yu Chang
- Department of Gastroenterology, The First Hospital of Jilin University, Changchun 130021, Jilin Province, China
| | - Guo-Hua Jin
- Department of Gastroenterology, The First Hospital of Jilin University, Changchun 130021, Jilin Province, China
| | - Hai-Bo Sun
- Department of Gastroenterology, The First Hospital of Jilin University, Changchun 130021, Jilin Province, China
| | - Dong Yang
- Department of Gastroenterology, The First Hospital of Jilin University, Changchun 130021, Jilin Province, China
| | - Tong-Yu Tang
- Department of Gastroenterology, The First Hospital of Jilin University, Changchun 130021, Jilin Province, China
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11
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Uppaluri S, Jain MA, Ali H, Shingala J, Amin D, Ajwani T, Fatima I, Patel N, Kaka N, Sethi Y, Kapoor N. Pathogenesis and management of diabetic gastroparesis: An updated clinically oriented review. Diabetes Metab Syndr 2024; 18:102994. [PMID: 38579489 DOI: 10.1016/j.dsx.2024.102994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 02/25/2024] [Accepted: 03/20/2024] [Indexed: 04/07/2024]
Abstract
BACKGROUND AND AIMS Diabetic gastroparesis (DGp) is a common and preventable complication of uncontrolled diabetes mellitus (D.M.) and significantly affects the Quality of Life of patients. Diagnosis and management present as a clinical challenge due to the disease's complexity and limited effective therapeutic options. This review aims to comprehensively outline the pathogenesis, diagnosis, and management of diabetic gastroparesis, evaluating evolving approaches to guide clinicians and provide future recommendations. METHODS A literature review was conducted on scholarly databases of PubMed, Google Scholar, Scopus and Web of Science encompassing published articles, gray literature and relevant clinical guidelines. Data were synthesized and analyzed to provide a comprehensive overview of diabetic gastroparesis, focusing on pathogenesis, diagnosis, and management. RESULTS The review intricately explores the pathogenesis contributing to diabetic gastroparesis, emphasizing autonomic neuropathy, oxidative stress, inflammation, hormonal dysregulation, microbiota alterations, and gastrointestinal neuropathy. Primary management strategies are underscored, including lifestyle modifications, symptom relief, and glycemic control. The discussion encompasses pharmacological and surgical options, highlighting the importance of a multidisciplinary approach involving various healthcare professionals for comprehensive patient care. CONCLUSION This review offers a thorough understanding of pathogenesis, diagnosis, and management of diabetic gastroparesis, underlining evolving approaches for clinicians. A multidisciplinary approach is crucial to address both the physical and mental health aspects of diabetes and its complications.
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Affiliation(s)
- Srikar Uppaluri
- Kamineni Academy of Medical Sciences and Research Center, Hyderabad, India; PearResearch, Dehradun, India.
| | - Manisha Ashok Jain
- PearResearch, Dehradun, India; Shri Bhausaheb Hire Govt. Medical College, Dhule, Maharashtra, India.
| | - Hira Ali
- PearResearch, Dehradun, India; Chifeng University Medical College, China.
| | - Jay Shingala
- PearResearch, Dehradun, India; B.J. Medical College, Ahmedabad, India.
| | - Dhruti Amin
- PearResearch, Dehradun, India; GMERS Medical College and Hospital, Gotri, Vadodara, India.
| | - Trisha Ajwani
- PearResearch, Dehradun, India; Baroda Medical College, Gujarat, India.
| | - Irum Fatima
- PearResearch, Dehradun, India; Osmania Medical College, Hyderabad, India.
| | - Neil Patel
- PearResearch, Dehradun, India; GMERS Medical College, Himmatnagar, Gujarat, India.
| | - Nirja Kaka
- PearResearch, Dehradun, India; GMERS Medical College, Himmatnagar, Gujarat, India.
| | - Yashendra Sethi
- PearResearch, Dehradun, India; Government Doon Medical College, Dehradun, India.
| | - Nitin Kapoor
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, India.
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12
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Mandarino FV, Testoni SGG, Barchi A, Azzolini F, Sinagra E, Pepe G, Chiti A, Danese S. Imaging in Gastroparesis: Exploring Innovative Diagnostic Approaches, Symptoms, and Treatment. Life (Basel) 2023; 13:1743. [PMID: 37629600 PMCID: PMC10455809 DOI: 10.3390/life13081743] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 08/08/2023] [Accepted: 08/12/2023] [Indexed: 08/27/2023] Open
Abstract
Gastroparesis (GP) is a chronic disease characterized by upper gastrointestinal symptoms, primarily nausea and vomiting, and delayed gastric emptying (GE), in the absence of mechanical GI obstruction. The underlying pathophysiology of GP remains unclear, but factors contributing to the condition include vagal nerve dysfunction, impaired gastric fundic accommodation, antral hypomotility, gastric dysrhythmias, and pyloric dysfunction. Currently, gastric emptying scintigraphy (GES) is considered the gold standard for GP diagnosis. However, the overall delay in GE weakly correlates with GP symptoms and their severity. Recent research efforts have focused on developing treatments that address the presumed underlying pathophysiological mechanisms of GP, such as pyloric hypertonicity, with Gastric Peroral Endoscopic Myotomy (G-POEM) one of these procedures. New promising diagnostic tools for gastroparesis include wireless motility capsule (WMC), the 13 carbon-GE breath test, high-resolution electrogastrography, and the Endoluminal Functional Lumen Imaging Probe (EndoFLIP). Some of these tools assess alterations beyond GE, such as muscular electrical activity and pyloric tone. These modalities have the potential to characterize the pathophysiology of gastroparesis, identifying patients who may benefit from targeted therapies. The aim of this review is to provide an overview of the current knowledge on diagnostic pathways in GP, with a focus on the association between diagnosis, symptoms, and treatment.
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Affiliation(s)
- Francesco Vito Mandarino
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, 20132 Milan, Italy; (S.G.G.T.); (A.B.); (F.A.); (S.D.)
| | - Sabrina Gloria Giulia Testoni
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, 20132 Milan, Italy; (S.G.G.T.); (A.B.); (F.A.); (S.D.)
| | - Alberto Barchi
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, 20132 Milan, Italy; (S.G.G.T.); (A.B.); (F.A.); (S.D.)
| | - Francesco Azzolini
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, 20132 Milan, Italy; (S.G.G.T.); (A.B.); (F.A.); (S.D.)
| | - Emanuele Sinagra
- Gastroenterology & Endoscopy Unit, Fondazione Istituto G. Giglio, Contrada Pietra Pollastra Pisciotto, 90015 Cefalù, Italy;
| | - Gino Pepe
- Department of Nuclear Medicine, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, 20132 Milan, Italy; (G.P.); (A.C.)
| | - Arturo Chiti
- Department of Nuclear Medicine, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, 20132 Milan, Italy; (G.P.); (A.C.)
| | - Silvio Danese
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, 20132 Milan, Italy; (S.G.G.T.); (A.B.); (F.A.); (S.D.)
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13
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Gastroparesis: An Evidence-Based Review for the Bariatric and Foregut Surgeon. Surg Obes Relat Dis 2023; 19:403-420. [PMID: 37080885 DOI: 10.1016/j.soard.2023.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 02/24/2023] [Indexed: 03/06/2023]
Abstract
Gastroparesis is a gastric motility disorder characterized by delayed gastric emptying. It is a rare disease and difficult to treat effectively; management is a dilemma for gastroenterologists and surgeons alike. We conducted a systematic review of the literature to evaluate current diagnostic tools as well as treatment options. We describe key elements in the pathophysiology of the disease, in addition to current evidence on treatment alternatives, including nutritional considerations, medical and surgical options, and related outcomes.
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14
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Hayat M, Yang D, Draganov PV. Third-space endoscopy: the final frontier. Gastroenterol Rep (Oxf) 2023; 11:goac077. [PMID: 36632624 PMCID: PMC9831051 DOI: 10.1093/gastro/goac077] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 11/16/2022] [Accepted: 11/22/2022] [Indexed: 01/11/2023] Open
Abstract
Over the years, our growing experience with endoscopic submucosal dissection along with technological advances has solidified our comfort and knowledge on working in the submucosa, also referred to as the "third space." Per-oral endoscopic myotomy (POEM) was the first prototype third-space endoscopy (TSE) procedure, demonstrating the feasibility and clinical utility of endoscopic esophagogastric myotomy via submucosal tunneling. The launch of POEM accelerated the evolution of TSE from a vanguard concept to an expanding field with a wide range of clinical applications. In this review, we discuss the status and future directions of multiple TSE interventions.
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Affiliation(s)
- Maham Hayat
- Center for Interventional Endoscopy, AdventHealth, Orlando, FL, USA
| | - Dennis Yang
- Center for Interventional Endoscopy, AdventHealth, Orlando, FL, USA
| | - Peter V Draganov
- Corresponding author. Division of Gastroenterology, Hepatology and Nutrition, University of Florida, 1329 SW 16th Street, Room #5254, Gainesville, FL 32608, USA. Tel: +1-352-273-9474; Fax: +1-352-627-9002;
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15
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Nabi Z, Reddy DN. Submucosal endoscopy: the present and future. Clin Endosc 2023; 56:23-37. [PMID: 36617645 PMCID: PMC9902679 DOI: 10.5946/ce.2022.139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 07/17/2022] [Accepted: 07/22/2022] [Indexed: 01/10/2023] Open
Abstract
Submucosal endoscopy or third-space endoscopy utilizes the potential space between the mucosal and muscularis layers of the gastrointestinal tract to execute therapeutic interventions for various diseases. Over the last decade, endoscopic access to the submucosal space has revolutionized the field of therapeutic endoscopy. Submucosal endoscopy was originally used to perform endoscopic myotomy in patients with achalasia cardia, and its use has grown exponentially since. Currently, submucosal endoscopy is widely used to resect subepithelial tumors and to manage refractory gastroparesis and Zenker's diverticulum. While the utility of submucosal endoscopy has stood the test of time in esophageal motility disorders and subepithelial tumors, its durability remains to be established in conditions such as Zenker's diverticulum and refractory gastroparesis. Other emerging indications for submucosal endoscopy include esophageal epiphrenic diverticulum, Hirschsprung's disease, and esophageal strictures not amenable to conventional endoscopic treatment. The potential of submucosal endoscopy to provide easy and safe access to the mediastinum and peritoneal spaces may open doors to novel indications and rejuvenate the interest of endoscopists in natural orifice transluminal endoscopic surgery in the future. This review focuses on the current spectrum, recent updates, and future direction of submucosal endoscopy in the gastrointestinal tract.
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Affiliation(s)
- Zaheer Nabi
- Asian Institute of Gastroenterology, Hyderabad, India
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16
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Varvoglis DN, Farrell TM. Poor Gastric Emptying in Patients with Paraesophageal Hernias: Pyloroplasty, Per-Oral Pyloromyotomy, BoTox, or Wait and See? J Laparoendosc Adv Surg Tech A 2022; 32:1134-1143. [PMID: 35939274 DOI: 10.1089/lap.2022.0342] [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: 10/15/2022] Open
Abstract
Gastric emptying delay may be caused with both functional and anatomic derangements. Gastroparesis is suspected in patients presenting with certain foregut symptoms without anatomic obstruction. Data are still emerging regarding the best treatment of this condition. In cases where large paraesophageal hernias alter the upper gastrointestinal anatomy, it is difficult to know if gastroparesis also exists. Management of hiatal hernias is also still evolving, with various strategies to reduce recurrence being actively investigated. In this article, we present a systematic review of the existing literature around the management of gastroparesis and the management of paraesophageal hernias when they occur separately. In addition, since there are limited data to guide diagnosis and management of these conditions when they are suspected to coexist, we provide a rational strategy based on our own experience in patients with paraesophageal hernias who have symptoms or studies that raise suspicion for a coexisting functional disorder.
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Affiliation(s)
- Dimitrios N Varvoglis
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Timothy M Farrell
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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17
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Abstract
Gastroparesis is characterized by symptoms suggesting retention of food in the stomach with objective evidence of delayed gastric emptying in the absence of mechanical obstruction in the gastric outflow. This condition is increasingly encountered in clinical practice. These guidelines summarize perspectives on the risk factors, diagnosis, and management of gastroparesis in adults (including dietary, pharmacological, device, and interventions directed at the pylorus), and they represent the official practice recommendations of the American College of Gastroenterology. The scientific evidence for these guidelines was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation process. When the evidence was not appropriate for Grading of Recommendations, Assessment, Development, and Evaluation, we used expert consensus to develop key concept statements. These guidelines should be considered as preferred but are not the only approaches to these conditions.
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18
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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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19
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Meling S, Bertoli D, Sangnes DA, Brock C, Drewes A, Ejskjaer N, Dimcevski G, Søfteland E. Diabetic Gastroenteropathy: Soothe the Symptoms or Unravel a Cure? Curr Diabetes Rev 2022; 18:e220321192412. [PMID: 34225633 DOI: 10.2174/1573399817666210322154618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 01/19/2021] [Accepted: 02/13/2021] [Indexed: 11/22/2022]
Abstract
Autonomic neuropathy in patients with diabetes mellitus, and especially complications related to gastrointestinal neuropathy, are often overlooked in the clinic. Diabetic gastroenteropathy affects every segment of the gastrointestinal tract and generates symptoms that may include nausea, early satiety, vomiting, abdominal pain, constipation, and diarrhea. Severe cases can be complicated by weight loss, dehydration, and electrolyte disturbances. The pathophysiology is complex, the diagnostics and treatment options are multidisciplinary, and there is generally a lack of evidence for the treatment options. The aims for this review are first to summarize the pathophysiology and describe possible and expected symptoms and complications.Further, we will try to supply the clinician with a straightforward tool for diagnostics, and then, we shall summarize established treatment options, including diet recommendations, pharmacological and non-pharmacological options. Finally, we will explore the multiple possibilities of novel treatment, looking at medications related to the pathophysiology of neuropathy, other manifestations of autonomic neuropathies, and symptomatic treatment for other gastrointestinal disorders, also including new knowledge of endosurgical and neuromodulatory treatment. The overall goal is to increase awareness and knowledge on this frequent diabetic complication and to provide better tools for diagnosis and treatment. Ultimately, we hope to encourage further research in this field, as there are clear shortcomings in terms of biomarkers, pathophysiology, as well as treatment possibilities. In conclusion, diagnosis and management of diabetic gastroenteropathy are challenging and often require multidisciplinary teams and multimodal therapies. Treatment options are sparse, but new pharmacological, endoscopic, and neuromodulatory techniques have shown promising results in initial studies.
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Affiliation(s)
- Sondre Meling
- Department of Medicine, Stavanger University Hospital, Stavanger, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Davide Bertoli
- Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Dag A Sangnes
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Christina Brock
- Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
- Steno Diabetes Center North Jutland, Aalborg, Denmark
| | - Asbjørn Drewes
- Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
- Steno Diabetes Center North Jutland, Aalborg, Denmark
| | - Niels Ejskjaer
- Steno Diabetes Center North Jutland, Aalborg, Denmark
- Department of Clinical Medicine and Endocrinology, Aalborg University Hospital, Aalborg, Denmark
| | - Georg Dimcevski
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Eirik Søfteland
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
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20
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Abstract
Gastroparesis is characterized by symptoms suggestive of, and objective evidence of, delayed gastric emptying in the absence of mechanical obstruction. This review addresses the normal emptying of solids and liquids from the stomach and details the myogenic and neuromuscular control mechanisms, including the specialized function of the pyloric sphincter, that result in normal emptying, based predominantly on animal research. A clear understanding of fundamental mechanisms is necessary to comprehend derangements leading to gastroparesis, and additional research on human gastric muscles is needed. The section on pathophysiology of gastroparesis considers neuromuscular diseases that affect nonsphincteric gastric muscle, disorders of the extrinsic neural control, and pyloric dysfunction that lead to gastroparesis. The potential cellular basis for gastroparesis is attributed to the effects of oxidative stress and inflammation, with increased pro-inflammatory and decreased resident macrophages, as observed in full-thickness biopsies from patients with gastroparesis. Predominant diagnostic tests involving measurements of gastric emptying, the use of a functional luminal imaging probe, and high-resolution antral duodenal manometry in characterizing the abnormal motor functions at the gastroduodenal junction are discussed. Management is based on supporting nutrition; dietary interventions, including the physical reduction in particle size of solid foods; pharmacological agents, including prokinetics and anti-emetics; and interventions such as gastric electrical stimulation and pyloromyotomy. These are discussed briefly, and comment is added on the potential for individualized treatments in the future, based on optimal gastric emptying measurement and objective documentation of the underlying pathophysiology causing the gastroparesis.
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Affiliation(s)
- Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
| | - Kenton M. Sanders
- Department of Physiology and Cell Biology, University of Nevada, Reno School of Medicine, Reno, NV
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21
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Impact of Robotic Versus Laparoscopic Pyloroplasty on Short- and Long-term Outcomes in Patients with Gastroparesis. J Gastrointest Surg 2021; 25:2679-2680. [PMID: 33772401 PMCID: PMC9005204 DOI: 10.1007/s11605-021-04986-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 03/15/2021] [Indexed: 01/31/2023]
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22
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Shiu SI, Shen SH, Luo HN. Short-term outcomes of different modalities of pyloromyotomy versus gastric electrical stimulation in the treatment of gastroparesis: A systemic review and meta-analysis. Medicine (Baltimore) 2021; 100:e27291. [PMID: 34664890 PMCID: PMC8448004 DOI: 10.1097/md.0000000000027291] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 09/02/2021] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND The aim of this meta-analysis was to compare the short-term outcomes surrounding the efficacy and complication rate between different modalities of pyloromyotomy and gastric electrical stimulation (GES) in the treatment of gastroparesis. METHODS Comprehensive, computerized research was performed on PubMed, Embase, and the Cochrane Central Register of Controlled Trials. We additionally reviewed relevant articles, without any language limitations, published prior to April 15, 2020. Meta-analysis was conducted using RevMan 5.3 software. RESULTS Three studies totaling 196 participants who had received 4 interventions, including single per-oral pyloromyotomy (POP), double POP, laparoscopic pyloromyotomy, and GES, were eligible for analysis. Compared to single POP, double POP achieved a better clinical response with a pooled relative risk (RR) of 1.27 (95% confidence interval [CI], 1.01-1.60, P = .04), while laparoscopic pyloromyotomy and GES showed no difference with a pooled RR of 0.89 (95% CI, 0.74-1.08, P = .23) and 0.87 (95% CI, 0.73-1.04, P = .13), respectively. As for the recurrence and complication rates, only GES showed a borderline significance of recurrence in comparison to single POP (RR 2.17, 95% CI, 1.00-4.71, P = .05), while there were no differences in the remainder of the comparisons. CONCLUSIONS We conducted a detailed comparison of 3 modalities of pyloromyotomy and GES in the treatment of gastroparesis, with the results suggesting that double POP demonstrated better clinical success with similar recurrence and complication rates. In addition, GES may result in more recurrence amongst these interventions.
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Affiliation(s)
- Sz-Iuan Shiu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- Evidence-based Practice and Policymaking Committee, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Shih-Hsiung Shen
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Hua-Nong Luo
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
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Murray FR, Schindler V, Hente JM, Fischbach LM, Schnurre L, Deibel A, Hildenbrand FF, Tatu AM, Pohl D. Pyloric dilation with the esophageal functional lumen imaging probe in gastroparesis improves gastric emptying, pyloric distensibility, and symptoms. Gastrointest Endosc 2021; 94:486-494. [PMID: 33771556 DOI: 10.1016/j.gie.2021.03.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 03/14/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS The role of decreased pyloric distensibility in gastroparesis as measured by the endolumenal functional luminal imaging probe (EndoFLIP) has been receiving increasing attention. In this study, we present clinical outcomes to pyloric dilation with the esophageal FLIP (EsoFLIP) in regard to gastric emptying, symptom evolution, and FLIP metrics. METHODS Patients evaluated for gastroparesis (gastric emptying studies of t1/2 ≥180 minutes during 13C-octanoic acid breath test and/or gastric remnants during gastroscopy after a sufficient fasting period) were scheduled for EsoFLIP controlled pyloric dilation. Pre- and postprocedural gastric emptying studies, questionnaires (Patient Assessment of Upper GI Symptoms Severity Index [PAGI-SYM; including the Gastroparesis Cardinal Symptom Index] and Patient Assessment of Quality of Life Index [PAGI-QOL]), and FLIP metrics were documented. Dilation was conducted according to a self-developed algorithm. RESULTS Forty-six patients were analyzed (72% women; median age, 39 years [range, 18-88]). Etiologies of gastroparesis were diabetic in 10 patients (22%), idiopathic in 33 (72%), and postoperative in 3 (6%). Postprocedural gastric emptying time decreased from a median of 211 minutes to 179 minutes (P = .001). In accordance, pyloric distensibility, PAGI-SYM, PAGI-QOL, and Gastroparesis Cardinal Symptom Index values improved significantly. After a median follow-up of 3.9 months, 57% of all treated patients with returned questionnaires reported improved symptoms. CONCLUSIONS Pyloric EsoFLIP controlled dilation shows value in the treatment of gastroparesis, both subjectively and objectively. Long-term follow-up to assess efficacy and comparative trials are warranted.
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Affiliation(s)
- Fritz Ruprecht Murray
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Valeria Schindler
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Juliane Marie Hente
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Lara Maria Fischbach
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Larissa Schnurre
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Ansgar Deibel
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | | | - Aurora Maria Tatu
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Daniel Pohl
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
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24
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Jehangir A, Malik Z, Petrov RV, Parkman HP. EndoFLIP and Pyloric Dilation for Gastroparesis Symptoms Refractory to Pyloromyotomy/Pyloroplasty. Dig Dis Sci 2021; 66:2682-2690. [PMID: 32749636 DOI: 10.1007/s10620-020-06510-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 07/21/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Gastroparesis patients may undergo pyloromyotomy/pyloroplasty for chronic refractory symptoms. However, some patients have persistent symptoms. It is unknown if balloon dilation may improve their symptoms. AIMS We aimed to (1) assess if pyloric through-the-scope (TTS) balloon dilation results in symptom improvement in gastroparesis patients with suboptimal response to pyloromyotomy/pyloroplasty and (2) determine endoscopic functional luminal imaging probe (EndoFLIP) characteristics of these patients before dilation. METHODS Patients with severe gastroparesis refractory to pyloromyotomy/pyloroplasty seen from 2/2019 to 3/2020 underwent pyloric TTS dilation after assessing the pyloric characteristics using EndoFLIP. Patients completed Gastroparesis Cardinal Symptom Index (GCSI) pre-procedurally, and GCSI and Clinical Patient Grading Assessment Scale (CPGAS) on follow-ups. RESULTS Thirteen (ten females) patients (mean age 45.2 ± 5.1 years) with severe gastroparesis symptoms (mean GCSI total score 3.4 ± 0.3) after pyloromyotomy/pyloroplasty underwent pyloric TTS dilation. Overall, there was improvement in symptoms at 1-month follow-up (mean GCSI total score 3.0 ± 0.4, mean CPGAS score 1.6 ± 0.5, p < 0.05 for both), with five (38%) patients reporting symptoms somewhat/moderately better. The patients with symptom improvement had lower pre-dilation pyloric EndoFLIP distensibility at 30 ml, 40 ml, and 50 ml than patients with little/no improvement (all p < 0.05). CONCLUSIONS In gastroparesis patients with refractory symptoms after pyloromyotomy/pyloroplasty, pyloric TTS dilation improved symptoms in about a third of the patients. Patients with symptom improvement had lower pre-dilation pyloric distensibility on EndoFLIP suggesting incomplete myotomy, pyloric muscle regeneration, or pyloric stricture. Pyloric EndoFLIP followed by TTS dilation seems to be a promising treatment for some patients with gastroparesis symptoms refractory to pyloromyotomy/pyloroplasty.
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Affiliation(s)
- Asad Jehangir
- Gastroenterology Section, Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA
| | - Zubair Malik
- Gastroenterology Section, Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA
| | - Roman V Petrov
- Department of Thoracic Surgery, Temple University School of Medicine, Philadelphia, PA, USA
| | - Henry P Parkman
- Gastroenterology Section, Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA.
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Pavurala RB, Stanich PP, Krishna SG, Guturu P, Hinton A, Conwell DL, Balasubramanian G. Predictors of Early Readmissions in Hospitalized Patients With Gastroparesis: A Nationwide Analysis. J Neurogastroenterol Motil 2021; 27:408-418. [PMID: 34210906 PMCID: PMC8266506 DOI: 10.5056/jnm20105] [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: 05/11/2020] [Revised: 11/06/2020] [Accepted: 11/17/2020] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND/AIMS Gastroparesis is a chronic gastrointestinal disorder that frequently presents with symptoms that are difficult to manage, necessitating frequent hospitalizations. We sought to determine the predictors of early readmission due to gastroparesis based on etiology. METHODS We identified all adults discharged with a principal diagnosis of gastroparesis after hospitalization from the 2014 Nationwide Readmission Database. We compared etiology wise (diabetes, post-surgical, and idiopathic) early readmission. Multivariate regression analyses were performed to identify significant predictors of 30-day readmission. RESULTS A total of 12 689 patients were identified, 30.7% diabetic, 2.6% post-surgical, and 66.7% were idiopathic. Patients with diabetic gastroparesis were more likely to be readmitted within 30 days than idiopathic (adjusted odds ratio [aOR], 0.81; 95% confidence interval [CI], 0.69-0.94) and post-surgical gastroparesis (aOR, 0.58; 95% CI, 0.34-0.98). Pyloroplasty was associated with less likelihood of 30-day readmission (aOR, 0.45; 95% CI, 0.20-0.97). In addition, male gender (aOR, 1.18; 95% CI, 1.02-1.37), modified Elixhauser comorbidity score ≥ 3 (aOR, 1.38; 95% CI, 1.18-1.61), chronic pain syndrome (aOR, 1.41; 95% CI, 1.11-1.78), younger (18-64 years) age (aOR, 1.64; 95% CI, 1.34-2.00), need for percutaneous endoscopic gastrostomy/jejunostomy tube (aOR, 2.06; 95% CI, 1.21-3.52), and need for total parenteral nutrition (aOR, 1.70; 95% CI, 1.24-2.35) were associated with increased risk of 30-day readmission. CONCLUSION s One in 5 patients was readmitted with gastroparesis within 30 days. In the diabetic group, diabetes-related complications contributed to readmissions than gastroparesis. Pyloroplasty is associated with reduced early hospital readmission. Prospective studies are needed for validation of these results.
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Affiliation(s)
- Ravi B Pavurala
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Peter P Stanich
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Somashekar G Krishna
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Praveen Guturu
- Division of Gastroenterology and Hepatology, University of Texas Medical Branch, Galveston, TX, USA
| | - Alice Hinton
- Division of Biostatistics, College of Public Health, The Ohio State University, Columbus, OH, USA
| | - Darwin L Conwell
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Gokulakrishnan Balasubramanian
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Tan J, Shrestha SM, Wei M, Wang P, Shi J, Lu Y, Gao Q, Lu T, Zhou J, Shi R. Feasibility, safety, and long-term efficacy of gastric peroral endoscopic myotomy (G-POEM) for postsurgical gastroparesis: a single-center and retrospective study of a prospective database. Surg Endosc 2021; 35:3459-3470. [PMID: 32880749 PMCID: PMC8195960 DOI: 10.1007/s00464-020-07793-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Accepted: 07/07/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Postsurgical gastroparesis is recognized as a gastrointestinal dysfunction syndrome following foregut surgery. Gastric peroral endoscopic myotomy (G-POEM) is suggested as a minimally invasive therapy for gastroparesis. But the long-term efficacy and safety of G-POEM in treating postsurgical gastroparesis are rarely explored. METHODS The primary outcomes included the symptomatic improvement based on gastroparesis cardinal symptoms index (GCSI) and the improvement of gastric emptying. The secondary outcomes included the improvement of gastroesophageal reflux symptoms and complications of G-POEM. RESULTS The severity of postsurgical gastroparesis was not associated with the onset time and the course of the disease. G-POEM significantly reduced GCSI throughout the follow-up period (p < 0.0001). For different anastomotic site, a significant improvement of GCSI was found at 6 month post-G-POEM (F4,165 = 74.18, p < 0.0001). Subscale analysis of GCSI showed that nausea/vomiting, post-prandial fullness/early satiety, and bloating were improved significantly at 6-month post-G-POEM (p < 0.0001, respectively). Half-emptying and whole-emptying time were significantly shortened in patients with different anastomotic site post-G-POEM (half-emptying time: F3,174 = 65.44, p < 0.0001; whole-emptying time: F3,174 = 54.85, p < 0.0001). The emptying of ioversol was obviously accelerated after G-POEM. GCSI wasn't related to pyloric length, pyloric diameter, and thickness of pyloric wall. GERDQ was also used to evaluate the clinical efficacy of G-POEM. For each time points, GERDQ didn't differ significantly in patients with different anastomotic site (F4,104 = 0.8075, p = 0.5231). For patients with different anastomotic site, GERDQ was improved significantly at different time points (F4,104 = 59.11, p < 0.0001). The higher the esophageal anastomotic site was, the faster G-POEM improved the symptoms of gastroesophageal reflux. No one required re-hospitalization for any complication. CONCLUSION G-POEM is a minimally invasive therapy with long-term effectiveness and safety in treating postsurgical gastroparesis.
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Affiliation(s)
- Jiacheng Tan
- Department of Gastroenterology, Zhongda Hospital Southeast University, No. 87 Dingjiaqiao, Nanjing, 210009, Jiangsu, China
| | - Sachin Mulmi Shrestha
- Department of Gastroenterology, Zhongda Hospital Southeast University, No. 87 Dingjiaqiao, Nanjing, 210009, Jiangsu, China
| | - Ming Wei
- Department of Gastroenterology, Zhongda Hospital Southeast University, No. 87 Dingjiaqiao, Nanjing, 210009, Jiangsu, China
| | - Panpan Wang
- Department of Gastroenterology, Zhongda Hospital Southeast University, No. 87 Dingjiaqiao, Nanjing, 210009, Jiangsu, China
| | - Jinjun Shi
- Department of Ultrasound, Zhongda Hospital Southeast University, Nanjing, 210009, Jiangsu, China
| | - Yanjia Lu
- Department of Ultrasound, Zhongda Hospital Southeast University, Nanjing, 210009, Jiangsu, China
| | - Qi Gao
- Department of Ultrasound, Zhongda Hospital Southeast University, Nanjing, 210009, Jiangsu, China
| | - Tong Lu
- Department of Radiology, Zhongda Hospital Southeast University, Nanjing, 210009, Jiangsu, China
| | - Jun Zhou
- Medical Division, Yidu Cloud (Beijing) Technology Co., Ltd, Beijing, 100191, China
| | - Ruihua Shi
- Department of Gastroenterology, Zhongda Hospital Southeast University, No. 87 Dingjiaqiao, Nanjing, 210009, Jiangsu, China.
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Abstract
GOAL A comprehensive review of treatments for nausea and vomiting (N/V). BACKGROUND N/V are common symptoms encountered in medicine. While most cases of acute N/V related to a specific cause can be straightforward to manage, other cases of acute N/V such as chemotherapy-induced N/V and especially chronic unexplained N/V can be difficult to control, leading to a significant decline in the patient's quality of life and increased cost of medical care from repeated hospitalizations. STUDY Traditional management has relied on pharmacotherapy which may be inadequate in a certain proportion of these patients. Many of the medications used in the management of N/V have significant side effect profiles making the need for new and improved interventions of great importance. RESULTS This review covers a broad review of the pathophysiology of N/V, pharmacotherapy, including safety concerns and controversies with established pharmaceuticals, newer immunotherapies, bioelectrical neuromodulation (including gastric electrical stimulation), behavioral and surgical therapies, and complementary medicine. CONCLUSION On the basis of emerging understandings of the pathophysiology of N/V, improved therapies are becoming available.
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Affiliation(s)
| | - Robert T Luckett
- Department of Medicine, Division of Gastroenterology, Hepatology & Nutrition, University of Louisville
| | - Chris Moser
- Department of Medicine, University of Louisville
| | - Dipendra Parajuli
- Department of Medicine, Division of Gastroenterology, Hepatology & Nutrition, University of Louisville
- Robley Rex Va Medical Center, Louisville, KY
| | - Thomas L Abell
- Department of Medicine, Division of Gastroenterology, Hepatology & Nutrition, University of Louisville
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Abdelfatah MM, Noll A, Kapil N, Shah R, Li L, Nustas R, Li B, Luo H, Chen H, Xia L, Mekaroonkamol P, Shahnavaz N, Keilin S, Willingham F, Christie J, Cai Q. Long-term Outcome of Gastric Per-Oral Endoscopic Pyloromyotomy in Treatment of Gastroparesis. Clin Gastroenterol Hepatol 2021; 19:816-824. [PMID: 32450364 DOI: 10.1016/j.cgh.2020.05.039] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 05/15/2020] [Accepted: 05/18/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Gastric per oral endoscopic pyloromyotomy (GPOEM) is a promising treatment for gastroparesis. There are few data on the long-term outcomes of this procedure. We investigated long-term outcomes of GPOEM treatment of patients with refractory gastroparesis. METHODS We conducted a retrospective case-series study of all patients who underwent GPOEM for refractory gastroparesis at a single center (n = 97), from June 2015 through March 2019; 90 patients had more than 3 months follow-up data and were included in our final analysis. We collected data on gastroparesis cardinal symptom index (GCSI) scores (measurements of postprandial fullness or early satiety, nausea and vomiting, and bloating) and SF-36 questionnaire scores (measures quality of life). The primary outcome was clinical response to GPOEM, defined as a decrease of at least 1 point in the average total GCSI score with more than a 25% decrease in at least 2 subscales of cardinal symptoms. Recurrence was defined as a return to baseline GCSI or GCSI scores of 3 or more for at least 2 months after an initial complete response. The secondary outcome was the factors that predict GPOEM failure (no response or gastroparesis recurrence within 6 months). RESULTS At initial follow-up (3 to 6 months after GPOEM), 73 patients (81.1%) had a clinical response and significant increases in SF-36 questionnaire scores (indicating increased quality of life) whereas 17 patients (18.9%) had no response. Six months after GPOEM, 7.1% had recurrence. At 12 months, 8.3% of patients remaining in the study had recurrence. At 24 months, 4.8% of patients remaining in the study had a recurrence. At 36 months, 14.3% of patients remaining in the study had recurrence. For patients who experienced an initial clinical response, the rate of loss of that response per year was 12.9%. In the univariate and multivariate regression analysis, a longer duration of gastroparesis reduced the odds of response to GPOEM (odds ratio [OR], 0.092; 95% CI, 1.04-1.3; P = .001). On multivariate logistic regression, patients with high BMIs had increased odds of GPOEM failure (OR, 1.097; 95% CI, 1.022-1.176; P = .010) and patients receiving psychiatric medications had a higher risk of GPOEM failure (OR, 1.33; 95% CI, 0.110-1.008; P = .052). CONCLUSIONS In retrospective analysis of 90 patients who underwent GPOEM for refractory gastroparesis, 81.1% had a clinical response at initial follow-up of their procedure. 1 year after GPOEM, 69.1% of all patients had a clinical response and 85.2% of initial responders maintained a clinical response. Patients maintained a clinical response and improved quality of life for as long as 3 years after the procedure. High BMI and long duration gastroparesis were associated with failure of GPOEM.
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Affiliation(s)
- Mohamed M Abdelfatah
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Alan Noll
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Neil Kapil
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Rushikesh Shah
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Lianyong Li
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Rosemary Nustas
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Baiwen Li
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Hui Luo
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Huimin Chen
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Liang Xia
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Parit Mekaroonkamol
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Nikrad Shahnavaz
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Steven Keilin
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Field Willingham
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Jennifer Christie
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Qiang Cai
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, Georgia.
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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: 0.4] [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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Fonseca Mora MC, Milla Matute CA, Alemán R, Castillo M, Giambartolomei G, Schneider A, Szomstein S, Lo Menzo E, Rosenthal RJ. Medical and surgical management of gastroparesis: a systematic review. Surg Obes Relat Dis 2020; 17:799-814. [PMID: 33722476 DOI: 10.1016/j.soard.2020.10.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 10/23/2020] [Accepted: 10/26/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND Gastroparesis (GPS) is a rare disease with multiple etiologies that results in delayed gastric emptying. Diagnosis of GPS can be challenging due to its rather complex clinical presentation. Pharmacologic refractory cases require surgical interventions, all of which have yet to be standardized and characterized. OBJECTIVES We present a review of the literature and provide an update of current therapies for patients with GPS. SETTING Department of General Surgery, Academic Hospital, United States. METHODS We conducted a comprehensive search in PubMed, Google Scholar, and Embase of English-written articles published in the last 38 years, with an advance title search of "gastroparesis management." Other keywords included: "surgical management" and "refractory gastroparesis." Further references were obtained through cross-reference. RESULTS A total of 12,250 articles were selected after eliminating duplicates. Following thorough screening of selection criteria, 68 full-text articles were included for review. CONCLUSION GPS is a challenging disease to manage. Nutritional support must remain the primary approach, followed by either medical or surgical treatment modalities if necessary. In patients with refractory gastroparesis, adjunctive therapies have been proposed as promising long-term options.
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Affiliation(s)
- Maria C Fonseca Mora
- The Department of General Surgery and The Bariatric and Metabolic Institute at Cleveland Clinic, Weston, Florida
| | - Cristian A Milla Matute
- The Department of General Surgery and The Bariatric and Metabolic Institute at Cleveland Clinic, Weston, Florida
| | - Rene Alemán
- The Department of General Surgery and The Bariatric and Metabolic Institute at Cleveland Clinic, Weston, Florida
| | - Marco Castillo
- The Department of General Surgery and The Bariatric and Metabolic Institute at Cleveland Clinic, Weston, Florida
| | - Giulio Giambartolomei
- The Department of General Surgery and The Bariatric and Metabolic Institute at Cleveland Clinic, Weston, Florida
| | - Alison Schneider
- The Department of General Surgery and The Bariatric and Metabolic Institute at Cleveland Clinic, Weston, Florida
| | - Samuel Szomstein
- The Department of General Surgery and The Bariatric and Metabolic Institute at Cleveland Clinic, Weston, Florida
| | - Emanuele Lo Menzo
- The Department of General Surgery and The Bariatric and Metabolic Institute at Cleveland Clinic, Weston, Florida
| | - Raul J Rosenthal
- The Department of General Surgery and The Bariatric and Metabolic Institute at Cleveland Clinic, Weston, Florida.
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Watts LS, Baker JR, Lee AA, Harer K, Bowers N, Law R, Hasler WL. Impact of gastric per-oral endoscopic myotomy on static and dynamic pyloric function in gastroparesis patients. Neurogastroenterol Motil 2020; 32:e13892. [PMID: 32542920 DOI: 10.1111/nmo.13892] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 04/23/2020] [Accepted: 04/30/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Functional Lumen Imaging Probe (EndoFLIP) tests typically measure static pyloric parameters, but the pylorus exhibits phasic variations on manometry. Dynamic changes in pyloric function have not been quantified using EndoFLIP, and the impact of Gastric Per-Oral Endoscopic Myotomy (G-POEM) on static and dynamic pyloric activity in gastroparesis is unknown. METHODS EndoFLIP balloon inflation to 30, 40, and 50 mL was performed to measure mean, maximum, and minimum values and variability in pyloric diameter and distensibility before and after G-POEM in 20 patients with refractory gastroparesis. The impact of phasic contractions on these pyloric measures was compared. KEY RESULTS G-POEM increased mean (P < .0001) and maximum (P = .0002) pyloric diameters and mean (P = .02) and maximum (P = .02) pyloric distensibility on 50 mL EndoFLIP inflation but not intraballoon pressures or minimum diameters or distensibility. Temporal variability of pyloric diameter (P = .02) and distensibility (P = .02) also increased after G-POEM. Phasic coupled contractions propagating from the antrum through the pylorus were observed in 37.5% of recordings; other phasic activity including isolated pyloric contractions were seen in 23.3%. Variability of pyloric diameter and distensibility tended to be higher during recordings with phasic activity. Some pyloric responses to G-POEM were influenced by age, gastroparesis etiology, gastric emptying, and prior botulinum toxin injection. CONCLUSIONS & INFERENCES Pyloric activity exhibits dynamic changes on EndoFLIP testing in gastroparesis. G-POEM increases maximal but not minimal diameter and distensibility with increased variations, suggesting this therapy enhances pyloric opening but may not impair pyloric closure. Phasic pyloric contractions contribute to variations in pyloric activity.
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Affiliation(s)
- Lydia S Watts
- Division of Gastroenterology and Hepatology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Jason R Baker
- Division of Gastroenterology and Hepatology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Allen A Lee
- Division of Gastroenterology and Hepatology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Kimberly Harer
- Division of Gastroenterology and Hepatology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Nicole Bowers
- Division of Gastroenterology and Hepatology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Ryan Law
- Division of Gastroenterology and Hepatology, University of Michigan Health System, Ann Arbor, MI, USA
| | - William L Hasler
- Division of Gastroenterology and Hepatology, University of Michigan Health System, Ann Arbor, MI, USA
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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: 0.2] [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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Endoscopic Per-oral Pyloromyotomy for Gastroparesis: Initial Experience and Postoperative Comparison to Predicted Complications Following Laparoscopic Pyloromyotomy as Calculated by the ACS Risk Calculator. Surg Laparosc Endosc Percutan Tech 2020; 31:142-145. [PMID: 32941355 DOI: 10.1097/sle.0000000000000862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 08/17/2020] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Per-oral endoscopic pyloromyotomy (POP) is a promising new therapy in the treatment of gastroparesis, where the pyloric muscle is cut using an endoscopic tunneling technique. This study was designed to report outcomes from our initial experience and compare the rate of complications to the laparoscopic equivalent using the American College of Surgeons (ACS) risk calculator. METHODS Patients who underwent POP between August 2018 to May 2019 were prospectively followed in a database approved by the institutional review board. Preoperatively, patients were evaluated objectively with a 4-hour gastric emptying study (GES). Following POP, all patients were invited for repeat GES 3 months postoperatively. The same cohort was entered into the ACS risk calculator using laparoscopic pyloromyotomy (LPM) as the selected procedure. Complication risk of LPM was then compared with the actual complication rate of POP. RESULTS There were 11 patients that met study criteria (median age 52). Sixty-four percent (7/11) of patients agreed to do repeat GES postoperatively. Of those, 6 of 7 (86%) had normal GES (<10% emptying at 4 h) and the mean improvement was 36.4%. All patients were entered into the ACS risk calculator in which LPM (CPT code 43800) was used as a control. The postoperative complication rate was less than the median predicted risk of LPM in all categories including overall complications (0% vs. 10.05%), return to the operating room, (0% vs. 2.68%), and sepsis (0% vs. 1.42%). The rate of readmission (9% vs. 6.29%, P=0.65) was higher in the POP group than LPM predicted. Length of stay for all patients was significantly shorter than predicted (1.8 vs. 4.6 d, P<0.001). CONCLUSIONS All POP patients had objective improvement in their GES and 86% had normal GES following this procedure. POP had significantly lower morbidity and reduced length of stay compared with that predicted of the laparoscopic equivalent using the ACS risk calculator.
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Endoscopic and Surgical Treatments for Gastroparesis: What to Do and Whom to Treat? Gastroenterol Clin North Am 2020; 49:539-556. [PMID: 32718569 PMCID: PMC7391056 DOI: 10.1016/j.gtc.2020.04.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Gastroparesis is a complex chronic debilitating condition of gastric motility resulting in the delayed gastric emptying and multiple severe symptoms, which may lead to malnutrition and dehydration. Initial management of patients with gastroparesis focuses on the diet, lifestyle modification and medical therapy. Various endoscopic and surgical interventions are reserved for refractory cases of gastroparesis, not responding to conservative therapy. Pyloric interventions, enteral access tubes, gastric electrical stimulator and gastrectomy have been described in the care of patients with gastroparesis. In this article, the authors review current management, indications, and contraindications to these procedures.
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Kim D. The Optimal Pyloric Procedure: A Collective Review. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2020; 53:233-241. [PMID: 32793458 PMCID: PMC7409877 DOI: 10.5090/kjtcs.2020.53.4.233] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 06/02/2020] [Accepted: 06/10/2020] [Indexed: 01/04/2023]
Abstract
Vagal damage and subsequent pyloric denervation inevitably occur during esophagectomy, potentially leading to delayed gastric emptying (DGE). The choice of an optimal pyloric procedure to overcome DGE is important, as such procedures can lead to prolonged surgery, shortening of the conduit, disruption of the blood supply, and gastric dumping/bile reflux. This study investigated various pyloric methods and analyzed comparative studies in order to determine the optimal pyloric procedure. Surgical procedures for the pylorus include pyloromyotomy, pyloroplasty, or digital fracture. Botulinum toxin injection, endoscopic balloon dilatation, and erythromycin are non-surgical procedures. The scope, technique, and effects of these procedures are changing due to advances in minimally invasive surgery and postoperative interventions. Some comparative studies have shown that pyloric procedures are helpful for DGE, while others have argued that it is difficult to reach an objective conclusion because of the variety of definitions of DGE and evaluation methods. In conclusion, recent advances in interventional technology and minimally invasive surgery have led to questions regarding the practice of pyloric procedures. However, many clinicians still perform them and they are at least somewhat effective. To provide guidance on the optimal pyloric procedure, DGE should first be defined clearly, and a large-scale study with an objective evaluation method will then be required.
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Affiliation(s)
- Dohun Kim
- Department of Thoracic and Cardiovascular Surgery, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea
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Wellington J, Stuart P, Westcott C, Koch KL. Obstructive Gastroparesis: Patient Selection and Effect of Laparoscopic Pyloroplasty. J Gastrointest Surg 2020; 24:1778-1784. [PMID: 31270719 DOI: 10.1007/s11605-019-04240-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 04/21/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Functional obstructive gastroparesis is an understudied subtype of gastroparesis with normal 3 cycle per minute gastric myoelectrical activity that responds to botulinum toxin A injection and balloon dilation of the pylorus. AIMS To determine the effect of pyloroplasty on symptoms, weight, gastric emptying, and gastric myoelectrical activity in patients with gastroparesis and normal 3 cycle per minute gastric myoelectrical activity. METHODS Ten patients (average age 36 years with gastroparesis and normal 3 cycle per minute gastric myoelectrical activity) who had at least two successful endoscopic pyloric therapies and then underwent pyloroplasty were identified. Electrogastrography with water load satiety test was performed to determine gastric myoelectrical activity. Gastric emptying was measured with 4-h scintigraphy. KEY RESULTS Six months after pyloroplasty, nine of ten patients reported improved symptoms and weight increased an average of 6.4 lb (p = 0.04). The average percentage of meal retained at 4 h decreased from 47% before to 16% after pyloroplasty (p < 0.01) and normalized in six patients. After pyloroplasty, the percent distribution of gastric myoelectrical activity power in the 3 cycle per minute range decreased at each measured interval compared with pre-pyloroplasty (p < 0.01). CONCLUSIONS (1) Pyloroplasty in these patients with obstructive gastroparesis improved gastric emptying and decreased 3 cycle per minute gastric myoelectrical activity, consistent with relief of functional gastric outlet obstruction. (2) Pyloric neuromuscular dysfunction is a key factor in delayed emptying in patients with functional obstructive gastroparesis.
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Affiliation(s)
- Jennifer Wellington
- Section on Gastroenterology, Department of Surgical Services, Wake Forest Baptist Medical Center, Winston-Salem, NC, 27157, USA.,Section on Gastroenterology, University of Maryland Medical Center, Baltimore, MD, 21210, USA
| | - Paula Stuart
- Section on Gastroenterology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - Carl Westcott
- Section on Gastroenterology, Department of Surgical Services, Wake Forest Baptist Medical Center, Winston-Salem, NC, 27157, USA
| | - Kenneth L Koch
- Section on Gastroenterology, Department of Surgical Services, Wake Forest Baptist Medical Center, Winston-Salem, NC, 27157, USA. .,Section on Gastroenterology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, 27157, USA.
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Camilleri M, Sanders KM. Opiates, the Pylorus, and Gastroparesis. Gastroenterology 2020; 159:414-421. [PMID: 32389662 DOI: 10.1053/j.gastro.2020.04.072] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 04/14/2020] [Accepted: 04/16/2020] [Indexed: 02/07/2023]
Affiliation(s)
- Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Kenton M Sanders
- Department of Physiology and Cell Biology, University of Nevada, Reno School of Medicine, Reno, Nevada
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Mohan BP, Chandan S, Jha LK, Khan SR, Kotagiri R, Kassab LL, Ravikumar NPG, Bhogal N, Chandan OC, Bhat I, Hewlett AT, Jacques J, Ponnada S, Asokkumar R, Adler DG. 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 2020; 34:3352-3367. [PMID: 31583465 DOI: 10.1007/s00464-019-07135-9] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [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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Affiliation(s)
- Babu P Mohan
- Internal Medicine, Banner University Medical Center, University of Arizona, Tucson, AZ, USA
| | - Saurabh Chandan
- Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Lokesh K Jha
- Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Shahab R Khan
- Internal Medicine, Banner University Medical Center, University of Arizona, Tucson, AZ, USA
| | - Rajesh Kotagiri
- Internal Medicine, Banner University Medical Center, University of Arizona, Tucson, AZ, USA
| | | | - Naveen P G Ravikumar
- Internal Medicine, Buffalo General Hospital, University at Buffalo, Buffalo, NY, USA
| | - Neil Bhogal
- Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Ojasvini C Chandan
- Pediatric Gastroenterology, Hepatology & Nutrition, University of Nebraska Medical Center, Omaha, NE, USA
| | - Ishfaq Bhat
- Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Alexander T Hewlett
- Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Jeremie Jacques
- Limoges University Hospital, University of Limoges, Limoges, France
| | - Suresh Ponnada
- Internal Medicine, Carilion Roanoke Memorial Hospital, Roanoke, VA, USA
| | - Ravishankar Asokkumar
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore, Singapore
| | - Douglas G Adler
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, UT, USA.
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Rodriguez JH, Ponsky J. Per Oral Pyloromyotomy for Gastroparesis. Adv Surg 2020; 54:265-272. [PMID: 32713435 DOI: 10.1016/j.yasu.2020.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- John H Rodriguez
- Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, 9500 Euclid Avenue Mail Code A-100, Cleveland, OH 44195, USA.
| | - Jeffrey Ponsky
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, 9500 Euclid Avenue Mail Code A-100, Cleveland, OH 44195, 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: 0.4] [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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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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Katzka DA, Camilleri M. Treating the pylorus in gastroparesis: The new riddle wrapped in the ultimate enigma? Gastrointest Endosc 2020; 91:1300-1302. [PMID: 32439098 DOI: 10.1016/j.gie.2020.02.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 02/17/2020] [Indexed: 12/11/2022]
Affiliation(s)
- David A Katzka
- Clinical Enteric Neuroscience Translational and Epidemiological Research, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Efficacy and Safety of Dor Fundoplication in Patients with Severe Gastroparesis and Refractory Gastroesophageal Reflux Disease. GASTROINTESTINAL DISORDERS 2020. [DOI: 10.3390/gidisord2020013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Poor quality of life is a major problem in patients with gastroesophageal reflux disease (GERD). Delayed gastric emptying in patients with severe gastroparesis (GP) worsens GERD symptoms and particularly nocturnal heartburn and regurgitation refractory to medical therapy. With limited therapeutic options, a Nissen fundoplication may be considered but concerns for this surgery are inability to wretch and vomit post-op, increasing the risk of wrap rupture. Dor fundoplication, a 180–200 degree anterior wrap, may improve sphincter competency and provide symptom relieve while minimizing these concerns and avoiding vagal nerve damage.
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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: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [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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Thompson JS, Hewlett A, Lyden E, Scott JR, McBride C. Patient factors influence surgical options in gastroparesis. Am J Surg 2020; 220:1093-1097. [PMID: 32102759 DOI: 10.1016/j.amjsurg.2020.02.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 02/10/2020] [Accepted: 02/14/2020] [Indexed: 01/16/2023]
Abstract
BACKGROUND Patient selection for the diverse surgical procedures for gastroparesis remains poorly defined. Our aim was to evaluate how patient factors have determined our surgical approach to gastroparesis. METHODS 95 patients undergoing 105 surgical procedures for gastroparesis were reviewed. Patient factors were compared across six surgical procedures: gastric neurostimulator, pyloroplasty, neurostimulator plus pyloroplasty, sleeve gastrectomy, gastric bypass and gastrectomy. Global symptom severity was determined preoperatively and at last follow up. RESULTS There were significant differences in etiology, BMI and gastroesophageal reflux across the various operations. Patients undergoing pyloroplasty and gastrectomy; were more likely to have a postsurgical etiology. (p < .05) Patients undergoing sleeve gastrectomy and gastric bypass were more likely to have BMI >35. (p <.05) Those undergoing sleeve gastrectomy were less likely to have gastroesophageal reflux preoperatively. (p <.05) There was no difference in preoperative clinical stage across the procedures. CONCLUSION Patient factors influence choice of procedure in the surgical treatment of gastroparesis. Etiology of gastroparesis, BMI >35 and gastroesophageal reflux are important determinants.
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Affiliation(s)
- Jon S Thompson
- Department of Surgery, University of Nebraska Medical Center, USA.
| | | | - Elizabeth Lyden
- Department of College of Public Health, University of Nebraska Medical Center, USA
| | - James R Scott
- Department of Surgery, University of Nebraska Medical Center, USA
| | - Corrigan McBride
- Department of Surgery, University of Nebraska Medical Center, USA
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Du N, Wu P, Wang P, Du Y, Li K, Wang Z, Xu H, Zhu Z. Reconstruction Methods and Complications of Esophagogastrostomy and Jejunal Interposition in Proximal Gastrectomy for Gastric Cancer: A Meta-Analysis. Gastroenterol Res Pract 2020; 2020:8179254. [PMID: 32411203 PMCID: PMC7201443 DOI: 10.1155/2020/8179254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Revised: 12/07/2019] [Accepted: 12/28/2019] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Proximal gastrectomy is used for the treatment of primary gastric cancer by open or laparoscopic surgery in the upper third of the stomach. Esophagogastrostomy (EG) or jejunal interposition (JI) is widely used in various reconstruction methods after proximal gastrectomy. We conducted a meta-analysis of EG and JI for treatment of gastric cancer. MATERIALS AND METHODS A search of PubMed, Embase, MEDLINE, J-STAGE, and Cochrane Library identified retrospective series on EG and JI. Weight mean differences (WMDs), odds ratios (ORs), and 95% confidence intervals (CIs) were used to analyze the operation-related data and postoperative complications. Heterogeneity was evaluated by the I 2 test, and potential publication bias was assessed with Egger regression tests and sensitivity analysis. RESULTS Eight studies were selected, and 496 patients were included. EG group benefits were 44.81 min shorter operating time (P < 0.001), 56.58 mL less blood loss (P = 0.03), and 7.4 days shorter hospital stay time (P < 0.001) than the JI group. Between the two groups, there was no significant difference in anastomotic leakage; otherwise, the EG group had a lower risk of anastomotic stenosis (OR = 0.44, 95%CI = 0.20 to 0.97, P = 0.04), lower risk of intestinal obstruction (OR = 0.07, 95%CI = 0.01 to 0.43, P = 0.004), and higher risk of reflux esophagitis (OR = 2.47, 95%CI = 1.07 to 5.72, P = 0.03). CONCLUSION The results of our study indicated that EG has significant advantages during the perioperative period and in short-term outcomes compared to JI.
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Affiliation(s)
- Nan Du
- Department of Surgical Oncology, Department of General Surgery, First Affiliated Hospital, China Medical University, Shenyang, China
| | - Pei Wu
- Department of Surgical Oncology, Department of General Surgery, First Affiliated Hospital, China Medical University, Shenyang, China
| | - Pengliang Wang
- Department of Surgical Oncology, Department of General Surgery, First Affiliated Hospital, China Medical University, Shenyang, China
| | - Yuwei Du
- Department of Surgical Oncology, Department of General Surgery, First Affiliated Hospital, China Medical University, Shenyang, China
| | - Kai Li
- Department of Surgical Oncology, Department of General Surgery, First Affiliated Hospital, China Medical University, Shenyang, China
| | - Zhenning Wang
- Department of Surgical Oncology, Department of General Surgery, First Affiliated Hospital, China Medical University, Shenyang, China
| | - Huimian Xu
- Department of Surgical Oncology, Department of General Surgery, First Affiliated Hospital, China Medical University, Shenyang, China
| | - Zhi Zhu
- Department of Surgical Oncology, Department of General Surgery, First Affiliated Hospital, China Medical University, Shenyang, China
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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: 1.3] [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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Abstract
This review covers the epidemiology, pathophysiology, clinical features, diagnosis, and management of diabetic gastroparesis, and more broadly diabetic gastroenteropathy, which encompasses all the gastrointestinal manifestations of diabetes mellitus. Up to 50% of patients with type 1 and type 2 DM and suboptimal glycemic control have delayed gastric emptying (GE), which can be documented with scintigraphy, 13C breath tests, or a wireless motility capsule; the remainder have normal or rapid GE. Many patients with delayed GE are asymptomatic; others have dyspepsia (i.e., mild to moderate indigestion, with or without a mild delay in GE) or gastroparesis, which is a syndrome characterized by moderate to severe upper gastrointestinal symptoms and delayed GE that suggest, but are not accompanied by, gastric outlet obstruction. Gastroparesis can markedly impair quality of life, and up to 50% of patients have significant anxiety and/or depression. Often the distinction between dyspepsia and gastroparesis is based on clinical judgement rather than established criteria. Hyperglycemia, autonomic neuropathy, and enteric neuromuscular inflammation and injury are implicated in the pathogenesis of delayed GE. Alternatively, there are limited data to suggest that delayed GE may affect glycemic control. The management of diabetic gastroparesis is guided by the severity of symptoms, the magnitude of delayed GE, and the nutritional status. Initial options include dietary modifications, supplemental oral nutrition, and antiemetic and prokinetic medications. Patients with more severe symptoms may require a venting gastrostomy or jejunostomy and/or gastric electrical stimulation. Promising newer therapeutic approaches include ghrelin receptor agonists and selective 5-hydroxytryptamine receptor agonists.
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Affiliation(s)
- Adil E Bharucha
- Clinical Enteric Neuroscience Translational and Epidemiological Research Program, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Yogish C Kudva
- Division of Endocrinology. Mayo Clinic, Rochester, Minnesota
| | - David O Prichard
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
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Rodriguez J, Strong AT, Haskins IN, Landreneau JP, Allemang MT, El-Hayek K, Villamere J, Tu C, Cline MS, Kroh M, Ponsky JL. Per-oral Pyloromyotomy (POP) for Medically Refractory Gastroparesis: Short Term Results From the First 100 Patients at a High Volume Center. Ann Surg 2019; 268:421-430. [PMID: 30004920 DOI: 10.1097/sla.0000000000002927] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE For patients with gastroparesis, temporary pyloric disruption has been shown to improve symptoms and gastric emptying. Per-oral pyloromyotomy (POP) is an innovative endoscopic procedure to divide the pylorus from within a submucosal tunnel, as a corollary to surgical pyloromyotomy. Here we evaluate subjective and objective outcomes 12-weeks after POP at a high volume center. METHODS The first 100 consecutive patients undergoing POP were included, with procedure dates between January 2016 and October 2017. Patients were evaluated using the Gastroparesis Cardinal Symptom Index (GCSI), and 4-hour solid-phase scintigraphic gastric emptying studies (GES) prior to procedure and at 90 days post-POP RESULTS:: The study cohort was 85% female with a mean age of 45.0 ± 14.6 years. Gastroparesis etiologies were divided among idiopathic (56%), diabetic (21%), postsurgical (19%), and other in 4%. There were 67% of the patients who had previous endoscopic or surgical interventions for gastroparesis. Most POP procedures were performed in the operating room (97%) and were completed in an average of 33 minutes. Ten patients incurred complications (10%), which included 1 diagnostic laparoscopy and 2 cases of gastrointestinal bleeding. Overall GCSI improved from a preoperative mean of 3.82 ± 0.86 to 2.54 ± 1.2 (P < 0.001). The improvement in each GCSI subscore was also highly statistically significant. Among the patients with postoperative GES available, 78% had objectively better 4-hour emptying with a mean improvement in retention by 23.6% (P < 0.001). This included 57% of patients with normal gastric emptying post-POP. CONCLUSION For patients with medically refractory gastroparesis, POP results in both subjective and objective improvement in the majority of patients. Prior intervention does not obviate POP as a therapeutic option. POP should be included along the treatment algorithm for patients with gastroparesis as an organ-sparing procedure.
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Affiliation(s)
- John Rodriguez
- Section of Surgical Endoscopy, Department of General Surgery Cleveland Clinic, Cleveland, OH.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
| | - Andrew T Strong
- Section of Surgical Endoscopy, Department of General Surgery Cleveland Clinic, Cleveland, OH.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
| | - Ivy N Haskins
- Department of General Surgery, George Washington University, Washington DC
| | - Joshua P Landreneau
- Section of Surgical Endoscopy, Department of General Surgery Cleveland Clinic, Cleveland, OH
| | - Matthew T Allemang
- Section of Surgical Endoscopy, Department of General Surgery Cleveland Clinic, Cleveland, OH
| | - Kevin El-Hayek
- Section of Surgical Endoscopy, Department of General Surgery Cleveland Clinic, Cleveland, OH.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH.,Section of Hepato-Pancreato-Biliary Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - James Villamere
- Section of Surgical Endoscopy, Department of General Surgery Cleveland Clinic, Cleveland, OH
| | - Chao Tu
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| | - Michael S Cline
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH.,Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH
| | - Matthew Kroh
- Section of Surgical Endoscopy, Department of General Surgery Cleveland Clinic, Cleveland, OH.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH.,Digestive Disease Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Jeffrey L Ponsky
- Section of Surgical Endoscopy, Department of General Surgery Cleveland Clinic, Cleveland, OH.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
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Farmer AD, Bruckner-Holt C, Schwartz S, Sadler E, Kadirkamanthan S. Diabetic Gastroparesis: Perspectives From a Patient and Health Care Providers. J Patient Cent Res Rev 2019; 6:148-157. [PMID: 31414026 DOI: 10.17294/2330-0698.1689] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Gastroparesis is defined as a delay in gastric emptying in the absence of mechanical obstruction in the stomach. Gastroparesis has a number of causes, including postsurgical, secondary to medications, postinfectious, idiopathic, and as a complication of diabetes mellitus, where it is underrecognized. The cardinal symptoms of diabetic gastroparesis are nausea, early satiety, bloating, and vomiting. Diabetic gastroparesis is more common in females and has a cumulative incidence of 5% in type 1 diabetes and 1% in type 2 diabetes. It is associated with a reduction in quality of life and exerts a significant burden on health care resources. The pathophysiology of this disorder is incompletely understood. Diagnosis is made based on typical symptoms associated with the demonstration of delayed gastric emptying in the absence of gastric outlet obstruction. Gastric emptying scintigraphy is the gold standard for demonstrating delayed gastric emptying, but other methods exist including breath testing and the wireless motility capsule. Diabetic gastroparesis should be managed within a specialist multidisciplinary team, and general aspects involve dietary manipulations/nutritional support, pharmacological therapy, and surgical/endoscopic interventions. Specific pharmacological therapies include prokinetics and antiemetics, with several new medications in the drug development pipeline. Surgical/endoscopic interventions include botulinum toxin injection into the pylorus, gastric peroral endoscopic myotomy and gastric electrical stimulation. This article provides a detailed review and summary of the epidemiology, pathophysiology, investigation, and management of diabetic gastroparesis, and also gives an individual patient's perspective of living with this disabling disorder.
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Affiliation(s)
- Adam D Farmer
- Institute of Applied Clinical Science, University of Keele, Keele, United Kingdom.,Department of Gastroenterology, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, United Kingdom
| | - Caroline Bruckner-Holt
- Department of Palliative Medicine, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, United Kingdom
| | - Susanne Schwartz
- Gastroparesis & Intestinal Failure Trust, Stafford, United Kingdom
| | - Emma Sadler
- Department of Research and Development, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, United Kingdom
| | - Sri Kadirkamanthan
- Department of Surgery, Broomfield Hospital NHS Trust, Chelmsford, United Kingdom
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