To establish a consensus on the definition and management of idiopathic gastroparesis, international experts (selected by neurogastroenterology and motility societies and initiated by the Rome Foundation) devised 144 statements using the Delphi method, with at least 80% agreement required. This consensus defined idiopathic gastroparesis as the presence of symptoms associated with delayed gastric emptying in the absence of mechanical obstruction. Nausea and vomiting were identified as cardinal symptoms. Frequently co-existing symptoms are early satiation and postprandial fullness. Diagnosis requires the presence of these symptoms alongside delayed gastric emptying, measured by a 4 h scintigraphy or gastric emptying breath test of a mixed composition meal in the absence of mechanical obstruction. Therapeutic options with proven efficacy were sparse. Dietary adjustments, nutritional support (per guidelines from the European Society for Clinical Nutrition and Metabolism for substantial weight loss or intractable vomiting), and opioid cessation were recommended by a consensus opinion. Antiemetic and prokinetic agents were also considered potentially beneficial. This consensus offers a global perspective on idiopathic gastroparesis.

Gastroparesis has a substantial impact on the quality of life but has limited treatment options, which makes it a public health concern. No bibliometric studies on gastroparesis have been published thus far. Thus, this article aims to summarize and analyze research hotspots to provide a reference for clinical researchers.

Gastroparesis-related research articles were searched in the Web of Science Core Collection (WOSCC), and relevant information was extracted after screening. A total of 1033 documents were analyzed with the bibliometric method using Microsoft Excel, Citespace, and VOSviewer.

Overall, our search retrieved 1033 papers contributed by 966 research institutions from 53 countries. Since 1980, publications in this field have increased rapidly. United States (n = 645) and Temple University (n = 122) were the most productive country and institution, respectively. Parkman, with 96 publications, was the most prominent author.

Research hotspots in gastroparesis can be summarized into four domains: innovation in diagnostic modalities, change of oral therapeutic agents, choice of surgical interventions, and pathological mechanisms. Future research on gastroparesis should focus on the quality of life of patients, diagnostic techniques, pyloromyotomy, and transpyloric stent placement.

Although pediatric neurogastroenterology and motility (PNGM) disorders are prevalent, often debilitating, and remain challenging to diagnose and treat, this field has made remarkable progress in the last decade. Diagnostic and therapeutic gastrointestinal endoscopy emerged as a valuable tool in the management of PNGM disorders. Novel modalities such as functional lumen imaging probe, per-oral endoscopic myotomy, gastric-POEM, and electrocautery incisional therapy have changed the diagnostic and therapeutic landscape of PNGM. In this review, the authors highlight the emerging role of therapeutic and diagnostic endoscopy in esophageal, gastric, small bowel, colonic, and anorectal disorders and disorders of gut and brain axis interaction.

Gastroparesis is delayed gastric emptying without mechanical obstruction. Symptomatic improvement can be 50-60% with gastric electrical stimulation. To address delayed gastric emptying, pyloroplasty was added. This study examines the long-term efficacy and safety of simultaneous gastric electrical stimulator implantation and pyloroplasty.

In this prospective single-arm trial conducted from 2012 to 2015, 27 [23 females; mean age 43 (22-63)] gastroparesis patients who underwent simultaneous gastric electrical stimulator implantation with Heineke-Mikulicz pyloroplasty were studied. Six (25%) underwent simultaneous robot-assisted pyloroplasty and gastric electrical stimulator implantation. Diagnosis of gastroparesis was based on the 4-h gastric emptying test defined as >60% retention of isotope at 2 h and >10% at 4 h. Total symptom scores assessing severity of nausea, early satiety, bloating, vomiting, post-prandial fullness, and epigastric pain were obtained at baseline and at follow-up visits, ranging from 3 to 38 months (mean: 17).

Follow-up data from 24 patients were available for analysis. There was 71% improvement in total symptom score on follow-up. Mean retention decreased by 29.6 and 48.7% at 2 and 4 h and gastric emptying was normalized in 60%. There were no post-surgical complications.

Combination of gastric electrical stimulator and pyloroplasty significantly accelerated gastric emptying and improved gastroparesis symptoms. Combining these two surgical therapies improves both subjective and objective endpoints in drug refractory gastroparesis.

Controlled trials of gastric electrical stimulation (GES) for gastroparesis reported no significant improvement in symptoms, while open label studies suggested substantial clinical benefits.

To determine if GES is effective in reducing symptoms in patients with gastroparesis.

We searched PubMed and Embase for articles published in English (1990-2014) using "gastroparesis" as a search term restricted to "clinical trial". We included studies describing repeated patient-based symptom ratings before and during standardized treatments of at least one week duration.

Five studies randomly allocated patients to periods with or without GES. Total symptom severity (TSS) scores did not differ between these periods (0.17 [95% confidence interval: -0.06 to 0.4]; P=0.15). However, sixteen open label studies of GES showed a significant TSS decrease (2.68 [2.04-3.32]; Q=39.0; P<0.001). Other treatment modalities similarly improved TSS by 1.97 [1.5-2.44] for medical therapy (MED), by 1.52 [0.9-2.15] for placebo arms (PLA), and by 2.32 [1.56-3.06] for botulinum toxin (BTx). There were significant differences in baseline TSS ratings among these studies (GES: 6.28 [6.28-7.42]; MED: 4.76 [4.09-5.42]; PLA: 4.59 [3.77-5.42]; BTx: 6.02 [5.3-6.74]; Q=35.1; P<0.001). Meta-regression analysis showed these baseline differences to significantly impact TSS ratings during treatment (Q=71.8; P<0.001).

Independent of the treatment modality, baseline symptom severity impacts treatment results in gastroparesis. Considering the skewed population with refractory symptoms, regression to the mean likely contributes to the substantial discrepancies between the reported results of controlled and open label GES studies, raising questions about the use of GES outside of defined clinical trials.

Vomiting and abdominal pain are common in patients in the emergency department. This article focuses on small bowel obstruction (SBO), cyclic vomiting, and gastroparesis. Through early diagnosis and appropriate management, the morbidity and mortality associated with SBOs can be significantly reduced. Management of SBOs involves correction of physiologic and electrolyte disturbances, bowel rest and removing the source of the obstruction. Treatment of acute cyclic vomiting is primarily directed at symptom control, volume and electrolyte repletion, and appropriate specialist follow-up. The mainstay of therapy for gastroparesis is metoclopramide.

Gastric electrical stimulation (GES) is neurostimulation; its mechanism of action is affecting central control of nausea and vomiting and enhancing vagal function. GES is a powerful antiemetic available for patients with refractory symptoms of nausea and vomiting from gastroparesis of idiopathic and diabetic causes. GES is not indicated as a way of reducing abdominal pain in gastroparetic patients. The need for introducing a jejunal feeding tube means intensive medical therapies are failing, and is an indication for the implantation of the GES system, which should always be accompanied by a pyloroplasty to guarantee accelerated gastric emptying.

Although many surgical procedures originally associated with gastroparesis are less commonly performed nowadays, several more recently developed upper abdominal procedures may be complicated by the development of gastroparesis. Gastroparesis has been described in association with neurologic disorders ranging from Parkinson disease to muscular dystrophy, and its presence may have important implications for patient management and prognosis. Although scleroderma is most frequently linked with gastrointestinal motility disorder, gastroparesis has been linked to several other connective tissue disorders. The management of these patients presents several challenges, and is best conducted in the context of a dedicated and skilled multidisciplinary team.

Controversy still exists about the need for pyloric drainage procedures after esophagectomy with gastric conduit reconstruction. Although pyloric drainage may prevent postoperative delayed gastric emptying (DGE), it may also promote dumping syndrome and bile reflux. The aims of this study were to audit the incidence and management of DGE in patients without routine pyloric drainage after esophagectomy in a university medical center.

From July 2006 to June 2012, data from 356 consecutive patients who underwent esophagectomy with a gastric conduit without pyloric drainage for esophageal or gastric cardia carcinoma were reviewed. Major observation parameters were the incidence, management, and outcomes of DGE.

Overall incidence of DGE was 15.7% (56 of 356). Early DGE developed in 26 patients, and late DGE developed in 30 patients. There were no differences in demographic and intraoperative data between the two groups with or without DGE. More DGE was documented in patients with an intra-right thoracic gastric conduit (P=.031). A higher incidence of postoperative pneumonia was observed in patients exhibiting early DGE, but without significance (P=.254). There were also no significant impacts on respiratory failure (P=.848) and anastomotic leakage (P=.257). There was an increased postoperative hospital stay with DGE, but without significance (P=.089). Endoscopic balloon dilatation of the pylorus was used to manage 33.9% of patients with DGE, yielding a 78.9% (15 of 19) success rate without complications. In 3 patients endoscopy showed the pylorus was open, and their symptoms improved over time. One patient with tumor-related DGE was treated by pyloric stent. The remaining patients were adequately treated with conservative management.

Omitting the operative drainage procedure does not lead to an increased frequency of DGE after esophagectomy with a gastric conduit. Many patients responded to conservative management, and endoscopic balloon pyloric dilatation can be effective in managing the DGE postoperatively.

Improvement of gastroparesis (GP) symptoms has been documented in patients treated with gastric electrical stimulation (GES), but acceleration of gastric emptying (GET) is unpredictable. The aim of our study was to evaluate the advantage of adding surgical pyloroplasty (PP) to GES for improvement of GET and control of symptoms in diabetes mellitus (DM), idiopathic (ID), and postvagotomy (P-V) GP.

A total of 49 (17 - DM, 9 - ID, 23 - P-V) consecutive GP patients: 38 female; mean age 42 (21-73 years); mean weight 158 lbs (102-245), underwent GES implantation, and 26 (53%) additionally received PP. Total Symptoms Score, 4-h GET, adverse events (AEs), and days of hospitalizations were captured at baseline and at the last visit.

The mean follow-up was 7 months. Total Symptoms Score in patients who received Enterra and PP or GES alone significantly improved compared to their baseline scores (P < 0.001). GET improved by 64% at 4 h (P < 0.001) in patients with Enterra and PP, compared to 7% observed after GES therapy alone (ns). The most impressive acceleration of GET was seen in the P-V group, who received both therapies (P = 0.004) and 8 (60%) of them normalized GET. No AEs accompanied the addition of PP to the Enterra surgery.

(i) In drug-refractory GP the addition of PP to GES substantially accelerated GET; (ii) The GET response in P-V group was the most impressive; (iii) Significant symptom reductions were achieved by both procedures; and (iv) PP added to GES may sustain better long-term symptoms control particularly in the P-V setting.

Botulinum toxin (BTX), the exotoxin of the obligate anaerobe, Clostridium botulinum, is used to ameliorate pain and treat conditions associated with glandular, smooth and skeletal muscle overactivity. The benefits derived from the injection of BTX may be negated by unintended weakness of uninjected muscles. Performance of BTX injections may be facile, requiring only surface marking or clinical-localisation techniques but may be more technically demanding, necessitating the use of equipment, such as electromyography (EMG) or ultrasonography (U/S). Less often, endoscopic, fluoroscopic or computed tomographic (CT) guidance may be required. Despite evidence to support the efficacy of BTX injections in treating many conditions, there is no evidence to support the superiority of any one injection technique over needle localisation using surface anatomy. This is possibly due to the lack of well-designed controlled studies, that is, current studies are hampered by small patient numbers, lack of consistency of injection technique and the application of different rating scales. Intuitively, certain injection techniques are more suited to injection of specific muscles or conditions, for example, U/S or passive-monitoring EMG should be used to treat cervical dystonia, active-monitoring EMG applied for strabismus injections, whereas either active-monitoring EMG or endoscopy is indicated when giving BTX for spasmodic dysphonia. Finally, electrical-stimulation EMG or U/S (or a combination of both) would be most suitable when injecting the forearm muscles for spasticity or writer's cramps.

Because the rate of acquired pyloric stenosis (APS) from truncal vagotomy is 15%, many surgeons perform pyloroplasty or pyloromyotomy at the time of esophagectomy. Endoscopic pyloric balloon dilatation (EPBD) is another method to manage APS. This study evaluated a cohort treated with preoperative EPBD.

This is a retrospective review of all patients treated with preoperative EPBD and esophagectomy for cancer from 2002 to 2009 at Brigham and Women's Hospital, a tertiary care center. Outcome measures included need for subsequent surgery for gastric outlet obstruction, rate of pyloric stenosis noted on postoperative endoscopy, and complications.

Upon review of the series, 25 patients (80% male; median age, 63 [range 47-81] years) had outpatient preoperative EPBD and esophagectomies 1-2 weeks later and were included in the study. None had pyloroplasties or pyloromyotomies at the time of esophagectomy. Selected patients had postoperative endoscopy. Of the 25 patients, 20 had transhiatal esophagectomies, 3 had thoracoabdominal esophagectomies, and 2 had VATS 3-hole esophagectomies. Median follow-up time was 22 (range, 1-84) months. There were no complications from EPBD. There were no postoperative deaths. No patient needed a second operation for gastric outlet obstruction. All patients had postoperative barium swallows (BaS) or endoscopy or both. Only one patient (4%) required one postoperative EPBD to dilate a 16-mm pylorus. Three others had delayed gastric emptying on BaS with endoscopy showing each pylorus was wide open. Their symptoms improved with time.

In this cohort, preoperative EPBD in all patients combined with postoperative EPBD in one patient obviated the need for pyloroplasty. This approach merits further study in a larger cohort, particularly to determine whether preoperative EPBD is necessary or if only selected postoperative EPBD is sufficient.

Botulinum toxin A has been used in children to treat spastic disorders and recently for GI conditions. Open-label studies in adults with gastroparesis have reported an improvement in symptoms and gastric emptying after endoscopic intrapyloric botulinum injections (IPBIs), although placebo-controlled trials have shown conflicting results. Only a single case report of IPBI is available in children.

To determine the long-term clinical outcomes and predictive factors for IPBI response in children with gastroparesis refractory to medical therapy.

Retrospective review.

Single tertiary care center.

Children with refractory gastroparesis symptoms undergoing IPBIs.

IPBIs.

Clinical improvement and predictive factors for response.

A total of 70 injections were given to 47 patients (mean age 9.98 ± 6.5 years; 23 female patients) with follow-up in 45 patients. IPBI failed in 15 patients and was successful in 30 patients. The median duration of response to the first IPBI was 3.0 months (95% CI, 1.2-4.8). A total of 29 patients received a single IPBI, and 18 received multiple IPBIs. Older age and vomiting predicted response to initial IPBI, and male sex predicted response to repeat IPBI. Only 1 patient reported exacerbation of vomiting after IPBI resolving within a week.

The open-label and retrospective nature of the study.

IPBI is safe and may be effective in the management of children with symptoms of gastroparesis. Subgroups identifying who responded to the first IPBI include older patients and those presenting with vomiting, whereas male patients responded better to repeat IPBIs.

Gastroparesis is a chronic motility disorder of the stomach that involves delayed emptying of solids and liquids, without evidence of mechanical obstruction. Although no cause can be determined for the majority of cases, the disease often develops as a complication of abdominal surgeries or because of other underlying disorders, such as diabetes mellitus or scleroderma. The pathophysiology behind delayed gastric emptying is still not well-understood, but encompasses abnormalities at 3 levels--autonomic nervous system, smooth muscle cells, and enteric neurons. Patients will often cite nausea, vomiting, postprandial fullness, and early satiety as their most bothersome symptoms on history and physical examination. Those that present with severe disease may already have developed complications, such as the formation of bezoars or masses of undigested food. In patients suspected of gastroparesis, diagnostic evaluation requires an initial upper endoscopy to rule out mechanical causes, followed by a gastric-emptying scintigraphy for diagnosis. Other diagnostic alternatives would be wireless capsule motility, antroduodenal manometry, and breath testing. Once gastroparesis is diagnosed, dietary modifications, such as the recommendation of more frequent and more liquid-based meals, are encouraged. Promotility medications like erythromycin and antiemetics like prochlorperazine are offered for symptomatic relief. These agents may be frequently changed, as the right combination of effective medications will vary with each individual. In patients who are refractory to pharmacologic treatment, more invasive options, such as intrapyloric botulinum toxin injections, placement of a jejunostomy tube, or implantation of a gastric stimulator, are considered. Future areas of research are based on current findings from clinical studies. New medications, such as hemin therapy, are emerging because of a better understanding of the pathophysiology behind gastroparesis, and present treatment options, such as gastric electric stimulation, are evolving to be more effective. Regenerative medicine and stem cell-based therapies also hold promise for gastroparesis in the near future.

Gastroparesis is a syndrome characterized by delayed gastric emptying in the absence of mechanical obstruction. The most common underlying aetiology is diabetes mellitus; however, many cases are idiopathic. Pregnancy per se is associated with gastrointestinal neuromuscular dysfunction; however, reports of gastroparesis arising during pregnancy are rare. We report a case of severe gastroparesis and proximal small bowel paresis presenting during pregnancy.

Abnormalities of gastroduodenal motility are considered key players in the pathogenesis of upper gastrointestinal symptoms in disorders such as functional dyspepsia and gastroparesis. Abnormalities of sensory control are considered another important factor that contributes to symptom generation. This review summarizes recent progress in our understanding of gastroduodenal motility and sensitivity in health and in disease.

Although gastric and small intestinal motility remain an important focus of research, including the application of the SmartPill (SmartPill Corp., Buffalo, New York, USA) wireless motility monitoring capsule, duodenal sensitivity and low-grade duodenal inflammation are new areas of interest in the pathogenesis of functional dyspepsia. A number of genetic polymorphisms associated with functional dyspepsia are being investigated, but large-scale studies are still lacking. Central processing of visceral stimuli, and its role in the pathogenesis of functional dyspepsia, is another important emerging topic. Therapeutic studies have reported on novel pharmacological approaches in functional dyspepsia and gastroparesis, as well as gastric electrical stimulation in the treatment of refractory gastroparesis.

There is gradual progress in our understanding of the pathogenesis of gastroduodenal symptoms. Areas of recent advances including the recognition of low-grade duodenal inflammation, the role of central nervous system processing in visceral hypersensitivity and the exploration of novel pharmacotherapeutic approaches.

Gastroparesis is a chronic disorder of gastric motility characterized by delayed gastric empting in the absence of mechanical obstruction, which can lead to symptoms of nausea, vomiting, bloating, abdominal pain, postprandial fullness and weight loss. Although there are many etiologies, the primary causes are diabetes or are idiopathic. The mainstay of treatment is dietary and drug therapies. However, many patients will continue to suffer intractable symptoms despite these treatments. Gastric neurostimulation with the Enterra Therapy system has been approved for use under the Humanitarian Device Exemption by the US FDA. The device produces pulses of electrical stimulation that are delivered to the stomach continuously. One randomized clinical trial and multiple nonrandomized unblinded clinical trials and case series have documented improvement of symptoms in intractable diabetic and idiopathic gastroparesis. The purpose of this article is to introduce the Enterra Therapy gastric neurostimulator. Gastroparesis and its pathophysiology will be discussed in this clinical context to enhance the understanding of the device and its development. We will analyze the device in detail, its placement and the results of studies evaluating its efficacy.

Lung transplantation has become an effective therapeutic option for selected patients with end stage lung disease. Long-term survival is limited by chronic rejection manifest as bronchiolitis obliterans syndrome (BOS). The aspiration of gastric contents has been implicated as a causative or additive factor leading to BOS. Gastroesophageal reflux (GER) and altered foregut motility are common both before and after lung transplantation. Further, the normal defense mechanisms against reflux are impaired in the allograft. Recent studies using biomarkers of aspiration have added to previous association studies to provide a growing body of evidence supporting the link between rejection and GER. Further, the addition of high-resolution manometry (HRM) and impedance technology to characterize bolus transit and the presence and extent of reflux regardless of pH might better identify at-risk patients. Although additional prospective studies are needed, fundoplication appears useful in the prevention or treatment of post-transplant BOS.

This review will highlight the existing literature on the relationship of gastroesophageal reflux and altered motility to lung transplant rejection, particularly BOS. The article will conclude with a discussion of the evaluation and management of patients undergoing lung transplantation at our center.