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Dimino J, Kuo B. Current Concepts in Gastroparesis and Gastric Neuromuscular Disorders-Pathophysiology, Diagnosis, and Management. Diagnostics (Basel) 2025; 15:935. [PMID: 40218285 PMCID: PMC11988396 DOI: 10.3390/diagnostics15070935] [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: 02/04/2025] [Revised: 03/29/2025] [Accepted: 03/30/2025] [Indexed: 04/14/2025] Open
Abstract
Upper gastrointestinal concerns including gastroparesis-like symptoms affect a large portion of the population, and determining the culprit condition can be difficult due to largely shared symptoms, clinical course, pathophysiology, and treatment pathways. The understanding of gastric neuromuscular disorders (GNDs) is emerging as a heterogeneous group encompassing conditions from gastroparesis to functional dyspepsia with chronic nausea, early satiety, bloating, or abdominal pain, irrespective of gastric emptying. This article aims to review the current concepts in gastroparesis and GNDs including pathophysiology, diagnosis, and management. While some established standards in their diagnosis and management exist, a number of novel diagnostics are becoming available. Durable therapeutic options are notably limited for such common conditions with chronic and debilitating symptoms, and neuromodulators may play a key role in symptom control, which has been previously under-recognized and underutilized. Advances in both pharmacologic treatment targets as well as noninvasive and invasive interventions and devices show promise in improving the experience of patients with gastroparesis-like symptoms. At this time, treatment of GNDs requires comprehensive multidisciplinary care from providers to achieve successful treatment outcomes.
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Affiliation(s)
| | - Braden Kuo
- Center for Neurointestinal Health, Division of Gastroenterology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA;
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2
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Faramarzi Garousi F, Sedighiyan M, Ghodsi M. Efficacy of intragastric botulinum toxin A injection on patients with side effects caused by intragastric balloon placement intolerance: A case series study. Medicine (Baltimore) 2025; 104:e41411. [PMID: 40101033 PMCID: PMC11922430 DOI: 10.1097/md.0000000000041411] [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: 08/11/2024] [Accepted: 01/14/2025] [Indexed: 03/20/2025] Open
Abstract
RATIONALE Obesity is a global health concern, with intragastric balloon (IGB) placement serving as a nonsurgical intervention for weight management. However, intolerance due to severe gastrointestinal side effects often leads to premature removal, limiting its effectiveness. Botulinum toxin A (BTX-A) injection has been proposed as a potential strategy to improve IGB tolerance by modulating gastric motility. PATIENT CONCERNS This study reports a case series of patients who developed severe intolerance to IGB placement, including persistent nausea, vomiting, fluid intolerance, dehydration, and reduced urine output, necessitating medical intervention. DIAGNOSES Patients were diagnosed with IGB intolerance due to obstructive gastric effects, characterized by impaired gastric emptying and intolerance to oral fluids, leading to dehydration and electrolyte imbalances. INTERVENTIONS A total of 14 patients with IGB intolerance were treated with 500 U of BTX-A injected around the pyloric canal. Prokinetic drugs were also administered to support gastric motility. Patients were monitored for 6 months following the intervention. OUTCOMES Among the 14 patients, 11 (78.57%) showed a significant improvement in fluid tolerance within 12 hours of BTX-A injection and were able to retain the IGB without additional complications. Three patients (21.43%) did not improve and required early IGB removal. No major adverse effects related to BTX-A injection were observed. LESSONS BTX-A injection appears to be a promising adjunctive therapy to improve IGB tolerance in patients experiencing severe intolerance. These findings suggest a potential role for BTX-A in reducing the need for premature balloon removal, thereby enhancing weight loss outcomes. However, further randomized controlled trials with larger sample sizes are needed to confirm its efficacy, optimize dosage, and establish standardized treatment protocols.
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Affiliation(s)
- Farzad Faramarzi Garousi
- Department of Gastroenterology, Imam Hossein Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohsen Sedighiyan
- Department of Clinical Nutrition, Bahrami Hospital, Tehran University of Medical Science, Tehran, Iran
| | - Maryam Ghodsi
- Department of Pediatrics, School of Medicine, Bahrami Hospital, Tehran University of Medical Science, Tehran, Iran
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Schol J, Huang IH, Carbone F, Fernandez LMB, Gourcerol G, Ho V, Kohn G, Lacy BE, Colombo AL, Miwa H, Moshiree B, Nguyen L, O'Grady G, Siah KTH, Stanghellini V, Tack J. Rome Foundation and international neurogastroenterology and motility societies' consensus on idiopathic gastroparesis. Lancet Gastroenterol Hepatol 2025; 10:68-81. [PMID: 39674226 DOI: 10.1016/s2468-1253(24)00284-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Revised: 08/25/2024] [Accepted: 08/27/2024] [Indexed: 12/16/2024]
Abstract
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.
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Affiliation(s)
- Jolien Schol
- Translational Research Center for Gastrointestinal Disorders, Leuven University, Leuven, Belgium; Division of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - I-Hsuan Huang
- Translational Research Center for Gastrointestinal Disorders, Leuven University, Leuven, Belgium; Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Florencia Carbone
- Division of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | | | - Guillaume Gourcerol
- Department of Physiology, UMR INSERM 1073 & CIC INSERM 1404, Rouen University Hospital, Rouen, France
| | - Vincent Ho
- School of Medicine, Western Sydney University, Sydney, NSW, Australia
| | - Geoffrey Kohn
- Department of Surgery, Monash University, Melbourne, VIC, Australia
| | - Brian E Lacy
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | - Aurelio Lopez Colombo
- UMAE, Hospital de Especialidades, Centro Médico Nacional Manuel Avila Camacho, Puebla, Mexico
| | - Hiroto Miwa
- Department of Internal Medicine, Kawanishi City Medical Center, Hyogo, Japan
| | - Baha Moshiree
- Atrium Health, Division of Gastroenterology, Hepatology, and Nutrition, Wake Forest Medical University, Charlotte, NC, USA
| | - Linda Nguyen
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Greg O'Grady
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Kewin T H Siah
- Division of Gastroenterology and Hepatology, University Medicine Cluster, National University Hospital, Singapore; Department of Internal Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Vincenzo Stanghellini
- Division of Internal Medicine, IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy
| | - Jan Tack
- Translational Research Center for Gastrointestinal Disorders, Leuven University, Leuven, Belgium; Division of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium; Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
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Gonzalez JM, Mion F, Pioche M, Garbay V, Baumstarck K, Boucekine M, Debourdeau A, Rivory J, Barthet M, Vitton V. Gastric peroral endoscopic myotomy versus botulinum toxin injection for the treatment of refractory gastroparesis: results of a double-blind randomized controlled study. Endoscopy 2024; 56:345-352. [PMID: 38141620 DOI: 10.1055/a-2235-3286] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2023]
Abstract
INTRODUCTION Gastric peroral endoscopic myotomy (G-POEM) is a promising technique for treating refractory gastroparesis. We present the first double-blind randomized study comparing the clinical efficacy of G-POEM versus pyloric botulinum toxin injection (BTI). METHODS This randomized study, conducted in two expert centers, enrolled patients with refractory gastroparesis, medically managed for >6 months and confirmed by gastric emptying scintigraphy (GES), into two groups, G-POEM versus BTI, with follow-up of 1 year. The primary end point was the 3-month clinical efficacy, defined as a >1-point decrease in the mean Gastroparesis Cardinal Symptom Index (GCSI) score. Secondary end points were: 1-year efficacy, GES evolution, adverse events, and quality of life. RESULTS 40 patients (22 women; mean age 48.1 [SD 17.4]), with mean symptom duration of 5.8 (SD 5.7) years, were randomized. Etiologies included idiopathic (n=18), diabetes (n=11), postoperative (n=6), and mixed (n=4). G-POEM showed a higher 3-month clinical success than BTI (65% vs. 40%, respectively; P=0.10), along with non-significantly higher 1-year clinical success (60% vs. 40%, respectively) on intention-to-treat analysis. The GCSI decreased in both groups at 3 months and 1 year. Only three minor adverse events occurred in the G-POEM group. The GES improvement rate was 72% in the G-POEM group versus 50% in the BTI group (non-significant). CONCLUSION G-POEM seems to have a higher clinically relevant success rate than BTI, but this was not statistically demonstrated. This study confirms the interest in treatments targeting the pylorus, either mechanically or chemically, for managing refractory gastroparesis.
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Affiliation(s)
| | | | - Mathieu Pioche
- Endoscopy Unit, Digestive Disease Department, Hôpital Edouard Herriot, Lyon, France
| | - Victor Garbay
- Hôpital Nord, Gastroenterology, AP-HM, Marseille, France
| | - Karine Baumstarck
- Public Health, Aix-Marseille Université Faculté de Medecine, Marseille, France
| | - Mohamed Boucekine
- Public Health, Aix-Marseille Université Faculté de Medecine, Marseille, France
| | | | - Jérôme Rivory
- Endoscopy Unit, Digestive Disease Department, Hôpital Edouard Herriot, Lyon, France
| | - Marc Barthet
- Hôpital Nord, Gastroenterology, AP-HM, Marseille, France
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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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Osgood PT, Essner BS, Fountain L, Sullivan EC, Meegan C, Fortunato JE. Intrapyloric Botulinum Toxin Injection for Refractory Nausea and Vomiting in Pediatric Patients. J Pediatr Gastroenterol Nutr 2023; 77:726-733. [PMID: 37794574 DOI: 10.1097/mpg.0000000000003954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/06/2023]
Abstract
OBJECTIVES Chronic nausea and vomiting may be associated with gastroparesis or other conditions. Poor mechanistic understanding of symptoms often precludes targeted therapy. Numerous case series suggest that intrapyloric botulinum toxin injection (IPBI) may be beneficial in treating gastroparesis and dyspepsia in children. We hypothesized that nausea, vomiting, and other symptoms, independent of gastroparesis, may improve with IPBI. We sought to identify gastric emptying (GE) and manometric patterns in IPBI responders versus nonresponders. METHODS Electronic records of 25 pediatric patients who received IPBI for refractory nausea, vomiting, or both were retrospectively reviewed. We assessed symptom improvement post-IPBI and compared symptoms, GE, and antroduodenal manometry (ADM) findings between IPBI responders and nonresponders. RESULTS At least one major symptom improved in 19 patients (76%) after IPBI. Of 22 patients completing a GE study, 14 had delayed GE with no significant difference between IPBI responders and nonresponders. Of 22 patients who underwent ADM, 18 had normal fasting peristalsis, 5 had postprandial antral hypomotility, 4 had neuropathic findings, and 19 had pylorospasm. IPBI responders, compared to nonresponders, demonstrated higher antral pressures with feeding ( P < 0.0001) and shorter duration of pylorospasm ( P = 0.0036). Antral pressures did not differ significantly with fasting or following motilin agonists. CONCLUSIONS Our findings suggest that IPBI may have therapeutic benefit in pediatric patients with chronic nausea and/or vomiting, independent of gastroparesis. ADM findings of intact antral peristalsis and elevated antral pressures, in conjunction with efficacy of IPBI, support pyloric non-relaxation as a potential contributor to nausea and/or vomiting in pediatric patients.
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Affiliation(s)
- Peter T Osgood
- From the Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Bonnie S Essner
- From the Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Laura Fountain
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Erin C Sullivan
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
| | - Carol Meegan
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - John E Fortunato
- From the Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
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Cangemi DJ, Lacy BE. Gastroparesis: Myths, Misconceptions, and Management. Clin Exp Gastroenterol 2023; 16:65-78. [PMID: 37303313 PMCID: PMC10257400 DOI: 10.2147/ceg.s362879] [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: 09/09/2022] [Accepted: 03/29/2023] [Indexed: 06/13/2023] Open
Abstract
Gastroparesis (GP), a historically vexing disorder characterized by symptoms of nausea, vomiting, abdominal pain, early satiety, and/or bloating, in the setting of an objective delay in gastric emptying, is often difficult to treat and carries a tremendous burden on the quality of patients' lives, as well as the healthcare system in general. Though the etiology of GP has been fairly well defined, much work has been done recently to better understand the pathophysiology of GP, as well as to identify novel effective and safe treatment options. As our understanding of GP has evolved, many myths and misconceptions still abound in this rapidly changing field. The goal of this review is to identify myths and misconceptions regarding the etiology, pathophysiology, diagnosis, and treatment of GP, in the context of the latest research findings which have shaped our current understanding of GP. Recognition and dispelling of such myths and misconceptions is critical to moving the field forward and ultimately advancing the clinical management of what will hopefully become a better understood and more manageable disorder in the future.
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Affiliation(s)
- David J Cangemi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | - Brian E Lacy
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
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Wadhwa V, Gonzalez A, Azar F, Singh H, Gupta K, Liang H, Schneider A, Ponsky J, Erim T, Rodriguez J, Castro FJ. Response to botulinum toxin may predict response to peroral pyloromyotomy in patients with gastroparesis. Endoscopy 2023; 55:508-514. [PMID: 36417930 DOI: 10.1055/a-1986-4292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
UNLABELLED BACKGROUND : Patients with gastroparesis who have undergone prior intrapyloric botulinum toxin injection (BTI) may seek an opinion regarding peroral pyloromyotomy (POP). There are only two small reports assessing the role of BTI as a predictor for successful treatment with POP. METHODS We performed a retrospective cohort study to assess whether symptomatic improvement after BTI predicts a response to POP. We included 119 patients who had undergone both BTI and POP at Cleveland Clinic Ohio or Cleveland Clinic Florida from January 2016 to September 2019. RESULTS 65.5 % of patients had symptomatic improvement after BTI. Gastroparesis Cardinal Symptom Index (GCSI) scores were available for 74 patients, with 64 % achieving a response to POP, defined as a decrease in mean GCSI ≥ 1. In multivariable analysis, response to BTI (odds ratio [OR] 7.7 [95 %CI 2.2-26.1]) and higher pre-POP GCSI score (OR 2.3 [95 %CI 1.2-4.6]) were independent predictors of response to POP. CONCLUSIONS Clinical improvement after BTI is a predictor of response to POP in patients with gastroparesis. This information may aid in improving patient selection for POP.
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Affiliation(s)
- Vaibhav Wadhwa
- Center for Interventional Gastroenterology, University of Texas Health Science, Houston, Texas, United States
| | - Adalberto Gonzalez
- Department of Gastroenterology and Hepatology, Cleveland Clinic Florida, Weston, Florida, United States
| | - Francisco Azar
- Department of Gastroenterology and Hepatology, Cleveland Clinic Florida, Weston, Florida, United States
| | - Harjinder Singh
- Department of Gastroenterology and Hepatology, Cleveland Clinic Florida, Weston, Florida, United States
| | - Kapil Gupta
- Department of Gastroenterology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, United States
| | - Hong Liang
- Department of Clinical Research, Cleveland Clinic Florida, Weston, Florida, United States
| | - Alison Schneider
- Department of Gastroenterology and Hepatology, Cleveland Clinic Florida, Weston, Florida, United States
| | - Jeffery Ponsky
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, United States
| | - Tolga Erim
- Department of Gastroenterology and Hepatology, Cleveland Clinic Florida, Weston, Florida, United States
| | - John Rodriguez
- Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, United States
| | - Fernando J Castro
- Department of Gastroenterology and Hepatology, Cleveland Clinic Florida, Weston, Florida, United States
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Khlevner J, Patel D, Rodriguez L. Pediatric Neurogastroenterology and Motility Disorders: What Role Does Endoscopy Play? Gastrointest Endosc Clin N Am 2023; 33:379-399. [PMID: 36948752 DOI: 10.1016/j.giec.2022.10.004] [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: 03/24/2023]
Abstract
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.
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Affiliation(s)
- Julie Khlevner
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Columbia University Vagelos College of Physicians and Surgeons, Gastrointestinal Motility Center, NewYork Presbyterian Morgan Stanley Children's Hospital, 622 West 168th Street, PH 17, New York, NY 11032, USA.
| | - Dhiren Patel
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Saint Louis University School of Medicine, SSM Cardinal Glennon Children's Medical Center, 1465 South Grand Boulevard, St Louis, MO 63104, USA
| | - Leonel Rodriguez
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Yale New Haven Children's Hospital, Yale School of Medicine, 333 Cedar Street, New Haven, CT 06510, USA
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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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Eriksson SE, Zheng P, Morton S, Maurer N, Hoppo T, Jobe BA, Ayazi S. Predictors of favorable outcome after pyloroplasty for gastroparesis: should response to pyloric dilation or Botox injection be used as a marker of surgical outcome? Surg Endosc 2023:10.1007/s00464-023-09882-2. [PMID: 36749378 DOI: 10.1007/s00464-023-09882-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 01/08/2023] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Pyloroplasty and gastric peroral endoscopic myotomy (G-POEM) are effective surgeries for gastroparesis. The primary aim of this study was to evaluate outcomes of pyloroplasty and G-POEM in patients with gastroparesis and determine factors associated with favorable outcome. The secondary aim was to assess the utility of clinical response to preoperative pyloric dilation or botulinum toxin injection (Botox) on surgical outcome, a factor conventionally used as a favorable marker. METHODS There were 204 patients who underwent pyloroplasty (n = 177) or G-POEM (n = 27) for gastroparesis at our institution from 2014 to 2021. Demographic and clinical parameters were analyzed to assess their impact on surgical outcome. A subgroup of patients who had pyloric dilation or Botox injection were assessed separately. Favorable outcome was defined as patient reported complete resolution of the predominant gastroparesis symptom. RESULTS Favorable outcome was achieved in 78.4% of patients (pyloroplasty: 79.7% and G-POEM: 70.4%, p = 0.274). Among 61 patients where pre- and postoperative gastric emptying studies (GES) were available, mean 4-hour retention significantly improved from 33.5 to 15.0% (p < 0.001) and 77.0% of patients achieved normalization. Favorable outcome was not significantly impacted by etiology of gastroparesis (p = 0.120), GERD (p = 0.518), or primary gastroparesis symptom (p = 0.244). Age ≥ 40 was a significant predictor of favorable surgical outcome on multivariate analysis [OR: 2.476 (1.224-5.008), p = 0.012]. Among the patients who had preoperative dilation (n = 82) or Botox injection (n = 46), response to these interventions was not a predictor of favorable surgical outcome (p = 0.192 and 0.979, respectively). However, preoperative Botox injection, regardless of response to injection, was associated with favorable surgical outcome [OR: 3.205 (CI 1.105-9.299), p = 0.032]. CONCLUSION Symptomatic improvement after pyloroplasty or G-POEM is independent of etiology of gastroparesis, GERD, and primary symptom. Response to dilation or Botox are not markers of response to surgery. However, patients who receive Botox are 3.2 times more likely to improve postoperatively.
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Affiliation(s)
- Sven E Eriksson
- Esophageal Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
| | - Ping Zheng
- Esophageal Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
| | - Scott Morton
- Esophageal Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
| | - Nicole Maurer
- Esophageal Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
| | - Toshitaka Hoppo
- Esophageal Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
| | - Blair A Jobe
- Esophageal Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA.,Department of Surgery, Drexel University, Philadephia, PA, USA
| | - Shahin Ayazi
- Esophageal Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA. .,Department of Surgery, Drexel University, Philadephia, PA, USA.
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Hirsch S, Nurko S, Liu E, Rosen R. A prospective study of intrapyloric botulinum toxin and EndoFLIP in children with nausea and vomiting. Neurogastroenterol Motil 2022; 34:e14428. [PMID: 35811408 PMCID: PMC9648533 DOI: 10.1111/nmo.14428] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 05/19/2022] [Accepted: 06/14/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND Intrapyloric botulinum toxin injection (IPBI) is used to treat nausea and vomiting in children, but no prospective pediatric studies exist. The aims of the current study were to assess the efficacy of IPBI in children with refractory nausea or vomiting and to use EndoFLIP as a biomarker of IPBI response. METHODS This was a prospective observational cohort study of pediatric patients undergoing IPBI for refractory nausea, vomiting, or feeding difficulties at a tertiary center. Patients completed validated questionnaires at baseline and 1, 2, and 3 months after IPBI. A subset of patients >10 years old underwent pyloric EndoFLIP at the time of IPBI. Symptoms were compared pre- and post-IPBI, and EndoFLIP measurements were assessed in relation to baseline characteristics and response to IPBI. KEY RESULTS Forty-five patients (mean age 14.2 ± 6.0 years) received IPBI, and 23 of those patients underwent EndoFLIP. Twenty-nine patients (64%) had symptomatic improvement at 1-month follow-up, including improvements in overall GI symptoms (p = 0.003), nausea and vomiting (p = 0.009), and discomfort when eating (p = 0.006). Symptomatic improvements lasted up to 3 months. There was a trend towards lower pyloric distensibility in patients with delayed versus normal gastric emptying (4.5 ± 3.8 mm2 /mmHg in delayed vs. 8.9 ± 6.6 mm2 /mmHg in normal, p = 0.09), though there were no differences in EndoFLIP measurements between IPBI responders and non-responders (p > 0.05). CONCLUSIONS AND INFERENCES The majority of patients responded to IPBI, with significant improvements seen in nausea, vomiting, and discomfort. Pyloric EndoFLIP tended to distinguish baseline delays in gastric emptying, but it did not predict IPBI response in this patient cohort.
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Affiliation(s)
- Suzanna Hirsch
- Aerodigestive Center, Center for Motility and Functional Gastrointestinal Disorders, Division of Gastroenterology, Hepatology & Nutrition, Boston Children’s Hospital, Boston, MA
| | - Samuel Nurko
- Aerodigestive Center, Center for Motility and Functional Gastrointestinal Disorders, Division of Gastroenterology, Hepatology & Nutrition, Boston Children’s Hospital, Boston, MA
| | - Enju Liu
- Institutional Centers for Clinical and Translational Research, Boston Children’s Hospital, Boston, MA
| | - Rachel Rosen
- Aerodigestive Center, Center for Motility and Functional Gastrointestinal Disorders, Division of Gastroenterology, Hepatology & Nutrition, Boston Children’s Hospital, Boston, MA
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13
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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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14
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Comparative Study of Pyloromyotomy and H-M Pyloroplasty in Proximal Gastrectomy for Adenocarcinoma of Esophageal-Gastric Junction. J Gastrointest Surg 2022; 26:1585-1595. [PMID: 35585422 DOI: 10.1007/s11605-022-05347-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 04/30/2022] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The incidence of adenocarcinoma of esophageal-gastric junction (AEJ) has been increasing in recent years. Esophagogastrostomy after proximal gastrectomy (PG-EG) is the most commonly used surgical method for this disease which causes a constant spasm of the pyloric sphincter by cutting the vagus nerve around the esophagus, so H-M pyloroplasty (Heineke-Mikulicz pyloroplasty) is often operated after PG-EG to prevent delayed gastric emptying. However, H-M pyloroplasty destroys anti-reflux structure of pylorus and leads to serious bile reflux. The present study was designed to compare pyloromyotomy and H-M pyloroplasty in proximal subtotal gastrectomy through clinical studies and animal experiments. METHODS We retrospectively evaluated the outcomes of 73 AEJ patients (39 underwent PG-EG with an H-M pyloroplasty and 34 underwent PG-EG with a pyloromyotomy) between January 2016 and August 2020, and perioperative variables were compared. In the animal experiment, 48 rats were randomly divided into four groups (n = 12): vagotomy group (V group), H-M pyloroplasty group (HM group), pyloromyotomy group (PM group), and control group (O group). Gastric emptying and bile reflux were evaluated in each group. RESULTS In the retrospective clinic study, pyloromyotomy and H-M pyloroplasty could all prevent delayed gastric emptying effectively, and the incidence of bile reflux found by electronic gastroscopy in the PM group was significantly lower than that in the HM group (HM, 14/39; PM, 4/34; P = 0.028). In the animal experiment, there was no significant between-group difference of gastric emptying rate (%) in the HM group and PM group (HM, 70.6 ± 16; PM, 72.3 ± 12; P = 0.68) while the gastric emptying rate (%) was significantly lower in the V group than in the HM, PM, and control group (P values were 0.037, 0.021, and 0.001 respectively). The gastric mucosa bile acid concentration was significantly higher in the HM group than other group (P values were all less than 0.001). CONCLUSIONS The pyloromyotomy could prevent delayed gastric emptying effectively after PG-EG for types II and III AEJ and reduce bile reflux compared to Heineke-Mikulicz pyloroplasty.
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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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Reja M, Mishra A, Tyberg A, Andalib I, Martínez GM, Zamarripa F, Gaidhane M, Nieto J, Kahaleh M. Gastric Peroral Endoscopic Myotomy: A Specific Learning Curve. J Clin Gastroenterol 2022; 56:339-342. [PMID: 34009842 DOI: 10.1097/mcg.0000000000001537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 02/18/2021] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Gastric peroral endoscopic pyloromyotomy (G-POEM) is a novel option for patients with gastroparesis. It involves submucosal tunneling across the pylorus, followed by pyloromyotomy, and subsequent closure of the endoscopic tunnel. The aim of this study was to determine the learning curve for G-POEM. METHODS Consecutive patients undergoing G-POEM by a single operator were included from a prospective registry over 2 years. Demographics, procedure info, postprocedure follow-up data, and adverse events were collected. Nonlinear regression and cumulative sum control chart analyses were conducted for the learning curve. Clinical outcomes were improvement in Gastroparesis Cardinal Symptom Index score and gastric emptying scintigraphy. RESULTS Thirty-six patients were included (16.7% M, mean age 46 y). The majority had idiopathic gastroparesis (n=16, 44%), with the remaining having diabetes (n=5, 17%), postsurgical (n=10, 28%), or other (n=4, 11%). Technical success was achieved in 35 of 36 (97%). There was a significant reduction in the total Gastroparesis Cardinal Symptom Index score (2.09 units, P<0.00001) and a significant reduction in postoperative gastric emptying scintigraphy (82.44 mins, P<0.00001). Mean follow-up was 15 months (SD, 1.05). Median procedure time was 60.5 minutes (range, 35 to 136). Cumulative sum control chart shows 60-minute procedure was achieved at the 18th procedure. Procedure durations further reduced with consequent procedures with the last 3 being 45 minutes, thus demonstrating continued improvement with ongoing experience (nonlinear regression P<0.0001). CONCLUSION Endoscopists experienced in G-POEM are expected to achieve a reduction in procedure time over successive cases, with efficiency reached at 60.5 minutes and a learning rate of 18 cases with continuing improvement.
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Affiliation(s)
- Mishal Reja
- Rutgers Robert Wood Johnson Medical School, New Brunswick
| | | | - Amy Tyberg
- Rutgers Robert Wood Johnson Medical School, New Brunswick
| | - Iman Andalib
- Ichan School of Medicine, Mount Sinai, New York, NY
| | | | | | | | | | - Michel Kahaleh
- Rutgers Robert Wood Johnson Medical School, New Brunswick
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17
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Li P, Ma B, Gong S, Zhang X, Li W. Gastric per-Oral Endoscopic Myotomy for Refractory Gastroparesis: A Meta-Analysis. J Gastrointest Surg 2021; 25:1108-1116. [PMID: 32394124 DOI: 10.1007/s11605-020-04520-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Accepted: 01/14/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND The emerging gastric per-oral endoscopic myotomy (G-POEM) is becoming an alternative treatment method for gastroparesis. This study aimed to evaluate the feasibility and safety of G-POEM for gastroparesis. METHODS Relevant publications were identified through searching PubMed, EMBASE, Cochrane Library, and Web of Science before April 1, 2019. Studies presenting the clinical data of G-POEM for the treatment of gastroparesis were included. Data about effectiveness and safety were extracted, pooled, and analyzed. Forest plots were graphed based on random effects models. RESULTS A total of 272 patients representing 8 studies were eligible for analysis. The pooled rates of GCSI at preprocedure, 1-3 months, 6 months, and 12 months, were 3.25 (95% CI, 2.75-3.75), 1.80 (95% CI, 1.10-2.49), 1.56 (95% CI, 0.45-2.68), and 1.10 (95% CI, 0.75-1.45), respectively. The pooled results of 4-h GES pre- and post-G-POEM were 41.89% (95% CI, 32.75-51.03%) and 16.48% (95% CI, 9.83-23.14%), respectively. Furthermore, the pooled clinical response rate was 84% (95% CI, 77-89%). The GES improvement rate and GES normal rate were also analyzed, and the results were 84% (95% CI, 77-90%) and 53% (95% CI, 39-66%), respectively. Finally, the pooled adverse events rate was 12% (95% CI, 6-19%). CONCLUSIONS G-POEM was shown to be feasible and safe for the treatment of gastroparesis with various etiologies, which could be a potential first-line therapy for certain patients. Future studies are needed to investigate the appropriate patients for G-POEM to explore the "most beneficial" subgroup of patients.
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Affiliation(s)
- Peiwen Li
- Department of Thoracic Surgery, The First Hospital of China Medical University, No.155 North Nanjing Street, Shenyang, 110001, People's Republic of China
| | - Bin Ma
- Department of Colorectal Surgery, Liaoning Cancer Hospital and Institute, Cancer Hospital of China Medical University, No. 44 Xiaoheyan Road, Dadong District, Shenyang, 110042, Liaoning Province, People's Republic of China
| | - Shulei Gong
- Department of Thoracic Surgery, The First Hospital of China Medical University, No.155 North Nanjing Street, Shenyang, 110001, People's Republic of China
| | - Xinyu Zhang
- Department of Thoracic Surgery, The First Hospital of China Medical University, No.155 North Nanjing Street, Shenyang, 110001, People's Republic of China
| | - Wenya Li
- Department of Thoracic Surgery, The First Hospital of China Medical University, No.155 North Nanjing Street, Shenyang, 110001, People's Republic of China.
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Cerise A, Chen JM, Powelson JA, Lutz AJ, Fridell JA. Pancreas transplantation would be easy if the recipients were not diabetic: A practical guide to post-operative management of diabetic complications in pancreas transplant recipients. Clin Transplant 2021; 35:e14270. [PMID: 33644895 DOI: 10.1111/ctr.14270] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 02/03/2021] [Accepted: 02/16/2021] [Indexed: 01/22/2023]
Abstract
Diabetes mellitus remains a major public health problem throughout the United States with over $300 billion spent in total cost of care annually. In addition to being a leading cost of kidney failure, diabetes causes a host of secondary hyperglycemic-related complications including gastroparesis and orthostatic hypotension. While pancreas transplantation has been established as an effective treatment for diabetes, providing long-term normoglycemia in recipients, the secondary complications of diabetes mellitus persist complicating the post-operative course of an otherwise successful pancreas transplantation. This review describes the mechanism and impact of diabetic gastroparesis and orthostatic hypotension in the post-operative course of pancreas transplant patients and analyzes the various treatment modalities, based on current data and extensive experience at our institution, to treat these respective complications. While gastroparesis and orthostatic hypotension remain challenging post-operative conditions, the establishment of institutional protocols and step-up treatment algorithms can help define more effective therapies.
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Affiliation(s)
- Adam Cerise
- Department of Surgery, Division of Abdominal Transplant Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jeanne M Chen
- Department of Surgery, Division of Abdominal Transplant Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - John A Powelson
- Department of Surgery, Division of Abdominal Transplant Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Andrew J Lutz
- Department of Surgery, Division of Abdominal Transplant Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jonathan A Fridell
- Department of Surgery, Division of Abdominal Transplant Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
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19
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Hirsch S, Nurko S, Mitchell P, Rosen R. Botulinum Toxin as a Treatment for Feeding Difficulties in Young Children. J Pediatr 2020; 226:228-235. [PMID: 32599032 PMCID: PMC9531944 DOI: 10.1016/j.jpeds.2020.06.063] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 05/28/2020] [Accepted: 06/19/2020] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To determine the effectiveness of intrapyloric botulinum toxin injection (IPBI) for treatment of feeding disorders and associated gastrointestinal symptoms in very young children. STUDY DESIGN A single-center retrospective study of patients 2 months to 5 years old who received IPBI at Boston Children's Hospital from May 2007 to June 2019 was performed. Charts were reviewed for demographic data, comorbidities, symptoms leading to IPBI, oral and tube feeding data, symptom improvement after IPBI, and need for repeat injections. The primary outcome was symptom improvement at the first gastroenterology clinic visit following IPBI. Secondary outcomes included improvement in oral feeding, decreases in tube feeding, and need for repeat injections. The χ2 or Fisher exact tests and multivariate logistic regression were used to identify factors associated with symptomatic improvement. RESULTS A total of 85 patients who received 118 injections were included in the final analysis; 57 patients (67%) had partial or complete improvement in symptoms after IPBI. Among the 55 patients with enteral tubes, there was an improvement in feeding, with more patients receiving at least some oral feeds after IPBI compared with before (26/55 vs 15/55; P = .004) and fewer patients receiving postpyloric feeds after IPBI compared with before (12/55 vs 21/55; P = .01). Twenty-six patients (31%) received repeat IPBI within 1 year, with only 6 patients receiving IPBI more than twice. CONCLUSIONS IPBI is safe and effective in young children. Children with enteral tubes show improvement in oral feeding and reduction in need for postpyloric feeding after IPBI.
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Affiliation(s)
- Suzanna Hirsch
- Aerodigestive Center, Center for Motility and Functional Gastrointestinal Disorders, Division of Gastroenterology, Hepatology & Nutrition, Boston Children’s Hospital, Boston, MA
| | - Samuel Nurko
- Aerodigestive Center, Center for Motility and Functional Gastrointestinal Disorders, Division of Gastroenterology, Hepatology & Nutrition, Boston Children’s Hospital, Boston, MA
| | - Paul Mitchell
- Institutional Centers for Clinical and Translational Research, Boston Children’s Hospital, Boston, MA
| | - Rachel Rosen
- Aerodigestive Center, Center for Motility and Functional Gastrointestinal Disorders, Division of Gastroenterology, Hepatology & Nutrition, Boston Children's Hospital, Boston, MA.
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20
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Gastric peroral endoscopic myotomy (G-POEM) for refractory gastroparesis: 3-month follow-up results. Dig Liver Dis 2020; 52:1215-1218. [PMID: 32819858 DOI: 10.1016/j.dld.2020.07.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 07/21/2020] [Accepted: 07/22/2020] [Indexed: 12/11/2022]
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21
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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: 15] [Impact Index Per Article: 3.0] [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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22
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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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23
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Reichenbach ZW, Stanek S, Patel S, Ward SJ, Malik Z, Parkman HP, Schey R. Botulinum Toxin A Improves Symptoms of Gastroparesis. Dig Dis Sci 2020; 65:1396-1404. [PMID: 31617132 DOI: 10.1007/s10620-019-05885-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 10/09/2019] [Indexed: 01/17/2023]
Abstract
BACKGROUND AND AIMS Pyloric injections of botulinum toxin A (BoNT/A) have shown benefit in open-label studies for patients with gastroparesis but not in randomized trials. We sought to examine the effectiveness of BoNT/A injections in a prospective open-label trial of patients with gastroparesis to assess specific symptom improvements over the course of 6 months. We also wanted to determine if specific biochemical measures including creatinine kinase, lactate dehydrogenase, aldolase, and C-reactive protein suggesting muscular injection could be used to predict successful response to pyloric injections of BoNT/A. METHODS Patients with gastroparesis undergoing pyloric BoNT/A injections for the treatment of symptomatic gastroparesis were enrolled. The patients completed the Gastroparesis Cardinal Symptom Index (GCSI) at the initial encounter and at 1, 3, and 6 months. Blood samples were collected before and 1 h after BoNT/A therapy. RESULTS We enrolled 34 patients for serum analysis of which 25 patients were available for symptom follow-up. Sixty-four percent of patients had an improvement in symptoms at 1 month. Patients with improved GCSI total score at 1 month had an improvement in most individual symptoms evaluated. For patients that improved at 1 month, this improvement often extended up to 6 months (p = 0.04). Serum measures studied did not correlate with clinical outcomes. CONCLUSIONS BoNT/A therapy to the pylorus provided symptomatic improvement at 1 month in 64% of patients. For those patients initially responding, the improvement can last out to 6 months. The biochemical markers did not serve to predict the outcome of injections.
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Affiliation(s)
- Zachary Wilmer Reichenbach
- Department of Gastroenterology, Temple University Hospital, 3401 N. Broad Street, Ambulatory Care Center, 3rd Floor, Philadelphia, PA, 19140, USA. .,Center for Substance Abuse Research (CSAR), Lewis Katz School of Medicine, Temple University, 3500 N. Broad Street, Medical Education and Research Bldg., 8th Floor, Philadelphia, PA, 19140, USA.
| | - Steven Stanek
- Department of Gastroenterology, Temple University Hospital, 3401 N. Broad Street, Ambulatory Care Center, 3rd Floor, Philadelphia, PA, 19140, USA
| | - Shyam Patel
- Department of Gastroenterology, Temple University Hospital, 3401 N. Broad Street, Ambulatory Care Center, 3rd Floor, Philadelphia, PA, 19140, USA
| | - Sara Jane Ward
- Center for Substance Abuse Research (CSAR), Lewis Katz School of Medicine, Temple University, 3500 N. Broad Street, Medical Education and Research Bldg., 8th Floor, Philadelphia, PA, 19140, USA
| | - Zubair Malik
- Department of Gastroenterology, Temple University Hospital, 3401 N. Broad Street, Ambulatory Care Center, 3rd Floor, Philadelphia, PA, 19140, USA
| | - Henry P Parkman
- Department of Gastroenterology, Temple University Hospital, 3401 N. Broad Street, Ambulatory Care Center, 3rd Floor, Philadelphia, PA, 19140, USA
| | - Ron Schey
- Department of Gastroenterology, Temple University Hospital, 3401 N. Broad Street, Ambulatory Care Center, 3rd Floor, Philadelphia, PA, 19140, USA
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Febo‐Rodriguez L, Chumpitazi BP, Shulman RJ. Childhood gastroparesis is a unique entity in need of further investigation. Neurogastroenterol Motil 2020; 32:e13699. [PMID: 31407456 PMCID: PMC7015769 DOI: 10.1111/nmo.13699] [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: 05/30/2019] [Revised: 07/23/2019] [Accepted: 07/30/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Despite increasing knowledge regarding gastroparesis (GP) in adults, little is known regarding the incidence, prevalence, and natural history of childhood GP. Exacerbating the knowledge gap in pediatric GP is both the lack of normative data for gastric emptying scintigraphy in children and lack of GP-specific pediatric reported outcome measures. PURPOSE The aim of this article was to review the available literature on pediatric GP and identify similarities and differences with studies in adults. We performed a comprehensive search in MEDLINE and Google Scholar from inception to April 2019 for articles published in English using the following combination of keywords: gastroparesis, pediatric gastroparesis, outcomes, metoclopramide, erythromycin, domperidone, cisapride, and gastric neurostimulator. The limited available pediatric data, often retrospective, suggest marked differences between adult and pediatric GP in several aspects including etiology, concomitant co-morbidities (eg, psychiatric disorders), clinical symptom presentation, diagnostic evaluation, response to therapies, and clinical outcome. Further research in pediatric GP is needed and holds the promise to further elucidate the mechanisms of this disorder in children and lead to pediatric-focused therapies.
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Affiliation(s)
- Liz Febo‐Rodriguez
- Department of Pediatrics, Baylor College of Medicine, Children's Nutrition Research Center, Section of Pediatric Gastroenterology, Hepatology, and Nutrition Texas Children's Hospital Houston TX USA
| | - Bruno P. Chumpitazi
- Department of Pediatrics, Baylor College of Medicine, Children's Nutrition Research Center, Section of Pediatric Gastroenterology, Hepatology, and Nutrition Texas Children's Hospital Houston TX USA
| | - Robert J. Shulman
- Department of Pediatrics, Baylor College of Medicine, Children's Nutrition Research Center, Section of Pediatric Gastroenterology, Hepatology, and Nutrition Texas Children's Hospital Houston TX USA
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25
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Cariati M, Chiarello MM, Cannistra' M, Lerose MA, Brisinda G. Gastrointestinal Uses of Botulinum Toxin. Handb Exp Pharmacol 2020; 263:185-226. [PMID: 32072269 DOI: 10.1007/164_2019_326] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Botulinum toxin (BT), one of the most powerful inhibitors that prevents the release of acetylcholine from nerve endings, represents an alternative therapeutic approach for "spastic" disorders of the gastrointestinal tract such as achalasia, gastroparesis, sphincter of Oddi dysfunction, chronic anal fissures, and pelvic floor dyssynergia.BT has proven to be safe and this allows it to be a valid alternative in patients at high risk of invasive procedures but long-term efficacy in many disorders has not been observed, primarily due to its relatively short duration of action. Administration of BT has a low rate of adverse reactions and complications. However, not all patients respond to BT therapy, and large randomized controlled trials are lacking for many conditions commonly treated with BT.The local injection of BT in some conditions becomes a useful tool to decide to switch to more invasive therapies. Since 1980, the toxin has rapidly transformed from lethal poison to a safe therapeutic agent, with a significant impact on the quality of life.
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Affiliation(s)
- Maria Cariati
- Department of Surgery, "San Giovanni di Dio" Hospital, Crotone, Italy
| | | | - Marco Cannistra'
- Department of Surgery, "San Giovanni di Dio" Hospital, Crotone, Italy
| | | | - Giuseppe Brisinda
- Department of Surgery, "San Giovanni di Dio" Hospital, Crotone, Italy. .,Department of Surgery, "Agostino Gemelli" Hospital, Catholic School of Medicine, Rome, Italy.
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Fathalizadeh A, Rodriguez J. Endoluminal Management of Gastroparesis. GASTROPARESIS 2020:55-76. [DOI: 10.1007/978-3-030-28929-4_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
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Desprez C, Melchior C, Wuestenberghs F, Zalar A, Jacques J, Leroi AM, Gourcerol G. Pyloric distensibility measurement predicts symptomatic response to intrapyloric botulinum toxin injection. Gastrointest Endosc 2019; 90:754-760.e1. [PMID: 31028783 DOI: 10.1016/j.gie.2019.04.228] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 04/16/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Recent studies have reported that pyloric distensibility was altered in 30% to 50% of patients with gastroparesis, and this was correlated with gastric emptying and symptom severity. The aim of this study was to assess whether pyloric distensibility measurement was predictive of symptomatic response after intrapyloric botulinum toxin (BT) injection. METHODS Pyloric distensibility was measured using the EndoFLIP system (Crospon, Galway, Ireland) before intrapyloric BT injection. Altered pyloric distensibility was defined as distensibility below 10 mm2/mm Hg. Total symptomatic score (TSS), dyspeptic symptoms, Gastrointestinal Quality of Life Index (GIQLI), and gastric emptying were investigated prospectively before and 3 months after BT injection. RESULTS Nineteen of 35 patients had altered pyloric distensibility. In those patients, TSS decreased at 3 months from 13.5 to 10.5 (P < .01), whereas it remained unchanged in patients with normal pyloric distensibility (P = .7). Gastric fullness (from 3.5 to 2.5; P = .03) and bloating (from 3.0 to 2.0; P = .01) were the only symptoms that improved in patients with altered pyloric distensibility, whereas none of them was improved in patients with normal pyloric distensibility. GIQLI score increased from 59.5 to 76.5 in patients with altered pyloric distensibility (P = .02), whereas there was no statistical difference (P = .43) in patients with normal pyloric distensibility. In patients with altered pyloric distensibility, gastric emptying half time was 223 minutes before and 190 minutes 3 months after injection (P = .02), whereas it remained unchanged in patients with normal pyloric distensibility (P = .6). CONCLUSIONS Pyloric distensibility measurement before intrapyloric BT injection predicted symptomatic and quality of life response 3 months after injection in patients with gastroparesis.
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Affiliation(s)
- Charlotte Desprez
- Digestive Physiology Unit, Rouen University Hospital, Rouen, France; Nutrition, Brain and Gut Laboratory UMR 1073, Rouen University, Rouen, France
| | - Chloé Melchior
- Nutrition, Brain and Gut Laboratory UMR 1073, Rouen University, Rouen, France; Gastroenterology Department, Rouen University Hospital, Rouen, France
| | - Fabien Wuestenberghs
- Digestive Physiology Unit, Rouen University Hospital, Rouen, France; Nutrition, Brain and Gut Laboratory UMR 1073, Rouen University, Rouen, France
| | - Alberto Zalar
- Gastroenterology Department, Rouen University Hospital, Rouen, France
| | - Jérémie Jacques
- Gastroenterology Department, Limoges University Hospital, Limoges, France
| | - Anne-Marie Leroi
- Digestive Physiology Unit, Rouen University Hospital, Rouen, France; INSERM CIC 1404, Rouen University Hospital, Rouen, France
| | - Guillaume Gourcerol
- Digestive Physiology Unit, Rouen University Hospital, Rouen, France; Gastroenterology Department, Rouen University Hospital, Rouen, France; INSERM CIC 1404, Rouen University Hospital, Rouen, France
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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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Loganathan P, Gajendran M, McCallum R. Current and future treatment management strategies for gastroparesis. Expert Opin Orphan Drugs 2019. [DOI: 10.1080/21678707.2019.1617694] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Priyadarshini Loganathan
- Department of Internal Medicine, Texas Tech University Health Sciences Center Paul L. Foster School of Medicine, El Paso, TX, USA
| | - Mahesh Gajendran
- Department of Internal Medicine, Texas Tech University Health Sciences Center Paul L. Foster School of Medicine, El Paso, TX, USA
| | - Richard McCallum
- Division of Gastroenterology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine, El Paso, TX, USA
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Mekaroonkamol P, Shah R, Cai Q. Outcomes of per oral endoscopic pyloromyotomy in gastroparesis worldwide. World J Gastroenterol 2019; 25:909-922. [PMID: 30833798 PMCID: PMC6397720 DOI: 10.3748/wjg.v25.i8.909] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Revised: 01/10/2019] [Accepted: 01/26/2019] [Indexed: 02/06/2023] Open
Abstract
Per oral endoscopic pyloromyotomy (POP), also known as gastric per-oral endoscopic myotomy (GPOEM), is a novel procedure with promising potential for the treatment of gastroparesis. As more data emerge and the procedure is becoming more recognized in clinical practice, its safety and efficacy need to be carefully evaluated. Appropriate patient selection for favorable clinical success prediction after GPOEM also needs additional research. This review aims to systemically summarize the existing data on clinical outcomes of POP. Symptomatologic responses to the procedure, its adverse effects, procedural techniques, and predictive factors of clinical success are also discussed.
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Affiliation(s)
- Parit Mekaroonkamol
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA 30322, United States
| | - Rushikesh Shah
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA 30322, United States
| | - Qiang Cai
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA 30322, United States
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Outcomes and Future Directions of Per-Oral Endoscopic Pyloromyotomy: A View from France. Gastrointest Endosc Clin N Am 2019; 29:139-149. [PMID: 30396523 DOI: 10.1016/j.giec.2018.08.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Gastroparesis is a challenging functional gastroenterological disorder, the complex pathophysiology of which hampers development of therapeutic modalities. Per-oral pyloromyotomy (POP) is a promising endoscopic therapy with a short-term clinical success rate of greater than 80%. Interest in POP is increasing, particularly in France, a country in which there is considerable expertise in submucosal endoscopy and functional disorders. Long-term follow-up and pyloric function evaluation are needed to assess the efficacy of POP in gastroparetic patients.
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Bekkelund M, Sangnes DA, Gunnar Hatlebakk J, Aabakken L. Pathophysiology of idiopathic gastroparesis and implications for therapy. Scand J Gastroenterol 2019; 54:8-17. [PMID: 30638082 DOI: 10.1080/00365521.2018.1558280] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Idiopathic gastroparesis is a gastric motility disorder characterized by chronic upper gastrointestinal symptoms and delayed gastric emptying without an identifiable underlying condition. This review summarizes recent understanding of the pathophysiology and treatment of idiopathic gastroparesis. MATERIALS AND METHODS Structured literature search in the PubMed, Embase and ClinicalTrials.gov databases. RESULTS Idiopathic gastroparesis involves several alterations in gastric motility and sensation, including delayed gastric emptying, altered myoelectrical activity, impaired fundic accommodation, visceral hypersensitivity and disturbances in antropyloroduodenal motility and coordination. Multiple cellular changes have been identified, including depletion of interstitial cells of Cajal (ICC) and enteric nerves, as well as stromal fibrosis. The underlying cause of these changes is not fully understood but may be an immune imbalance, including loss of anti-inflammatory heme-oxygenase-1 positive (HO-1) macrophages. There is currently no causal therapy for idiopathic gastroparesis. The treatment ladder consists of dietary measures, prokinetic and antiemetic medications, and varying surgical or endoscopic interventions, including promising pyloric therapies. There are ongoing trials with several novel medications, raising hopes for future treatment. CONCLUSIONS Patients with idiopathic gastroparesis present several pathophysiological alterations in the stomach, where depletion of ICC is of special importance. Treatment is currently focused on alleviating symptoms through dietary adjustments, medication or surgical or endoscopic interventions.
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Affiliation(s)
- Mattis Bekkelund
- a Faculty of Medicine, Department of Clinical Medicine , University of Oslo , Oslo , Norway.,b Department of Medicine , National Centre for Functional Gastrointestinal Disorders, Haukeland University Hospital , Bergen , Norway
| | - Dag A Sangnes
- b Department of Medicine , National Centre for Functional Gastrointestinal Disorders, Haukeland University Hospital , Bergen , Norway.,c Department of Medicine , Haukeland University Hospital , Bergen , Norway.,d Clinical institute 1, University of Bergen , Bergen , Norway
| | - Jan Gunnar Hatlebakk
- b Department of Medicine , National Centre for Functional Gastrointestinal Disorders, Haukeland University Hospital , Bergen , Norway.,c Department of Medicine , Haukeland University Hospital , Bergen , Norway.,d Clinical institute 1, University of Bergen , Bergen , Norway
| | - Lars Aabakken
- a Faculty of Medicine, Department of Clinical Medicine , University of Oslo , Oslo , Norway.,e Department of Transplantation Medicine , Section for Gastroenterology, Oslo University Hospital , Oslo , Norway
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Pasricha TS, Pasricha PJ. Botulinum Toxin Injection for Treatment of Gastroparesis. Gastrointest Endosc Clin N Am 2019; 29:97-106. [PMID: 30396531 PMCID: PMC6223662 DOI: 10.1016/j.giec.2018.08.007] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Refractory gastroparesis is among the most difficult therapeutic challenges in gastroenterology. Pyloric dysfunction has been described in a subset of patients with gastroparesis, prompting experimentation with botulinum toxin injections into the pylorus, which is relatively safe and has been successfully used in other gastrointestinal disorders. However, causality between pyloric dysfunction and symptoms of gastroparesis has never been demonstrated. Although several open-label studies showed initial promise, 2 randomized clinical trials failed to elicit a difference in clinical outcomes in botulinum toxin versus placebo. Based on current evidence, further use of botulinum toxin for gastroparesis is discouraged outside of a research trial.
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Affiliation(s)
- Trisha S. Pasricha
- Department of Medicine Baltimore, Junior Assistant Resident, Osler Medical Training Program Johns Hopkins Hospital, MD, USA
| | - Pankaj J. Pasricha
- Department of Gastroenterology, Professor of Medicine and Neurosciences, Johns Hopkins Hospital, Baltimore, MD, USA
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Abstract
Beneficial effects of pyloric botulinum toxin injection have been described in a subgroup of gastroparesis patients. Our aim is to evaluate whether clinical, manometric and/or scintigraphic parameters are able to predict treatment outcome. Forty patients (67% female, age 49 (36–56) years) with decompensated gastroparesis treated with botulinum toxin were included in this retrospective analysis. Objective parameters were high-resolution antroduodenal manometry, gastric emptying rate (scintigraphy), and weight change. Subjective treatment outcome was assessed with a Global Physician Assessment Scale. Binary logistic regression analysis was performed to identify predictors for treatment outcome. Fourteen patients (35%) were symptom-responders, and 65% of patients were short-term weight-responders. For both subjective and objective treatment outcome, no differences were found in manometric and scintigraphic variables between responders and non-responders. Neither clinical nor manometric or scintigraphic variables could predict subjective and objective treatment outcome. In conclusion, symptom improvement is achieved in a subgroup of gastroparesis patients treated with endoscopic pyloric botulinum toxin. Although the majority of patients were able to maintain their baseline weight at short-term follow-up, a substantial group of patients needed nutritional interventions on long-term follow-up. However, none of the demographic, clinical, scintigraphic, or antroduodenal manometry variables were able to predict either subjective or objective treatment outcome.
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Khoury T, Mizrahi M, Mahamid M, Daher S, Nadella D, Hazou W, Benson A, Massarwa M, Sbeit W. State of the art review with literature summary on gastric peroral endoscopic pyloromyotomy for gastroparesis. J Gastroenterol Hepatol 2018; 33:1829-1833. [PMID: 29806114 DOI: 10.1111/jgh.14293] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 05/09/2018] [Accepted: 05/12/2018] [Indexed: 12/18/2022]
Abstract
Gastroparesis is a debilitating progressive disease that significantly impacts a patient's life with limited and challenging treatments available. Although the pathogenesis is multifactorial, pylorospasm is believed to have a major underlying role. Several therapeutic interventions directed to the pylorus have been developed over the last decade, including intra-pyloric injections of botulinum toxin, transpyloric stenting, and surgical pyloroplasty. All of these treatment options had limited and disappointing results. More recently, gastric peroral endoscopic myotomy (G-POEM) has been reported as a treatment for refractory gastroparesis. In this review article, we provide an overview on gastroparesis with a focus on the therapeutic interventions. In addition, we provide a literature summary and pool analysis of the clinical efficacy, scintigraphic efficacy, and safety profile of all studies that evaluated G-POEM in gastroparesis. Overall, seven studies have reported on the use of G-POEM in gastroparesis, and the pooled analysis of these studies showed a technical success of 100%, with clinical efficacy as assessed by the Gastroparesis Cardinal Symptoms Index of 81.5%, gastric emptying scintigraphy normalization in approximately 55.5% of the cases, perioperative complications in 7.6%, and intraoperative complications in 6.6%. This suggests that G-POEM is a new promising therapeutic intervention for the treatment of gastroparesis with durable effect and limited potential adverse events.
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Affiliation(s)
- Tawfik Khoury
- The Liver Unit, Institute of Gastroenterology and Liver Diseases, Hebrew University-Hadassah Medical Center, Jerusalem, Israel
| | - Meir Mizrahi
- Internal Medicine, Division of Gastroenterology, University of South Alabama College of Medicine, Mobile, Alabama, USA
| | - Mahmud Mahamid
- Gastroenterology and Endoscopy United, The Nazareth Hospital, EMMS, Nazareth, Israel
| | - Saleh Daher
- The Liver Unit, Institute of Gastroenterology and Liver Diseases, Hebrew University-Hadassah Medical Center, Jerusalem, Israel
| | - Divya Nadella
- Internal Medicine, Division of Gastroenterology, University of South Alabama College of Medicine, Mobile, Alabama, USA
| | - Wadi Hazou
- The Liver Unit, Institute of Gastroenterology and Liver Diseases, Hebrew University-Hadassah Medical Center, Jerusalem, Israel
| | - Ariel Benson
- The Liver Unit, Institute of Gastroenterology and Liver Diseases, Hebrew University-Hadassah Medical Center, Jerusalem, Israel
| | - Muhammad Massarwa
- The Liver Unit, Institute of Gastroenterology and Liver Diseases, Hebrew University-Hadassah Medical Center, Jerusalem, Israel
| | - Wisam Sbeit
- Bar Ilan Faculty of Medicine, Institute of Gastroenterology and Liver Diseases, Galilee Medical Center, Naharia, Israel
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Kahaleh M, Gonzalez JM, Xu MM, Andalib I, Gaidhane M, Tyberg A, Saumoy M, Baptista Marchena AJ, Barthet M. Gastric peroral endoscopic myotomy for the treatment of refractory gastroparesis: a multicenter international experience. Endoscopy 2018; 50:1053-1058. [PMID: 29649841 DOI: 10.1055/a-0596-7199] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Gastroparesis is a difficult-to-treat motility disorder with a poor response to medical therapy. Gastric peroral endoscopic pyloromyotomy (G-POEM) has been offered as a novel therapy in the treatment of refractory gastroparesis. We present a multicenter case series of our experience with G-POEM. METHODS This is an international multicenter case series of patients who underwent G-POEM for the treatment of gastroparesis. The severity of gastroparesis was assessed by delayed gastric emptying scintigraphy (GES) and an elevated gastroparesis cardinal symptoms index (GCSI). Patients then underwent G-POEM using the submucosal tunneling technique. The primary endpoint was improvement in the GCSI score and improvement in gastric emptying on repeat scintigraphy. Secondary endpoints were technical success, complication rate, procedure duration, and length of hospital stay post-procedure. RESULTS G-POEM was technically successful in all 33 patients. Symptomatic improvement was seen in 28/33 patients (85 %), with a decrease in symptom score by GCSI from 3.3 to 0.8 at follow-up (P < 0.001). The mean procedure duration was 77.6 minutes (37 - 255 minutes). Mean GES improved significantly from 222.4 minutes to 143.16 minutes (P < 0.001). Complications were minimal and included bleeding (n = 1) and an ulcer (n = 1) treated conservatively. The mean length of hospital stay post-procedure was 5.4 days (1 - 14 days). The mean follow-up duration was 11.5 months (2 - 31 months). CONCLUSION G-POEM is a technically feasible, safe, and successful procedure for the treatment of refractory gastroparesis. A further multicenter comparative study should be performed to compare this technique to laparoscopic pyloromyotomy.
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Affiliation(s)
- Michel Kahaleh
- Rutgers Robert Wood Johnson, New Brunswick, New Jersey, USA
| | | | - Ming-Ming Xu
- Gastroenterology, Southern California Permanente Medical Group, Los Angeles, California, USA
| | - Iman Andalib
- Weill Cornell Medical Center, New York, New York, United States
| | | | - Amy Tyberg
- Rutgers Robert Wood Johnson, New Brunswick, New Jersey, USA
| | - Monica Saumoy
- Weill Cornell Medical Center, New York, New York, United States
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Jackson AS, Aye RW. Endoscopic Approaches to Cricopharyngeal Myotomy and Pyloromyotomy. Thorac Surg Clin 2018; 28:507-520. [DOI: 10.1016/j.thorsurg.2018.06.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Gastric Peroral Endoscopic Myotomy (G-POEM) as a Treatment for Refractory Gastroparesis: Long-Term Outcomes. Can J Gastroenterol Hepatol 2018; 2018:6409698. [PMID: 30425974 PMCID: PMC6217887 DOI: 10.1155/2018/6409698] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 08/26/2018] [Accepted: 09/27/2018] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND AND AIMS Gastric peroral endoscopic myotomy (G-POEM) has been regarded as a novel and minimally invasive therapy for refractory gastroparesis. This study reports the long-term outcomes and possible predictive factors for successful outcomes after G-POEM in an Asian population. METHODS This is a retrospective single-centre study of 16 patients who underwent G-POEM for refractory gastroparesis from August 2016 to October 2017. This study included 11 males and 5 females; in addition, 13 patients had postsurgical gastroparesis, and 3 patients had diabetes. The patients included had severe and refractory gastroparesis, as indicated by a Gastroparesis Cardinal Symptom Index (GCSI) score ≥20, and evidence of a delay on gastric emptying scintigraphy (GES). The primary outcome parameter was an assessment of the long-term clinical efficacy of the procedure. The secondary outcome parameter was the detection of possible predictive factors for success and the determination of cut-off values for such predictors. RESULTS Technical success was achieved in 100% of the patients, with a mean procedure time of 45.25±12.96 min. The long-term clinical response was assessed in all patients during a median follow-up of 14.5 months. Clinical success was achieved in 13 (81.25%) patients. There was a significant reduction in the GCSI scores and GES values after the procedure compared to the baseline values, with P values of <0.0001 and 0.012, respectively. Univariate regression analysis showed that the GCSI and GES had significant associations with the future clinical outcomes of the patients, but this finding was not confirmed in multivariate analysis. A GCSI cut-off score of ≤30 had a high sensitivity and a negative predictive value (NPV) of 100% for predicting a successful procedure. GES (half emptying time ≤221.6 min and 2-hour retention ≤78.6%) had a high specificity and a positive predictive value (PPV) of 100%. CONCLUSIONS G-POEM is a safe and effective treatment option with a long-term efficacy of 81.6%. GCSI and GES could serve as good predictive measures.
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Pyloric sphincter characteristics using EndoFLIP® in gastroparesis. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2018. [DOI: 10.1016/j.rgmxen.2018.06.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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Botulinum Toxin as a Treatment for Refractory Gastroparesis: a Literature Review. ACTA ACUST UNITED AC 2018; 16:479-488. [DOI: 10.1007/s11938-018-0187-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Abstract
Gastroparesis is defined as a combination of chronic dyspeptic symptoms and delayed emptying of a solid test meal. It remains a difficult-to-treat disorder with a significant impact on quality of life. Although gastroparesis is defined by delayed emptying, several important studies did not find a correlation between this biomarker and symptom severity or treatment success. Thus, some of the more recent trials explored strategies that ranged from antiemetics to antidepressants. Although dietary management showed benefit, most of the other interventions were barely superior to placebo or were not superior at all. Placebo responses were often quite high and this complicates the assessment of active agents. While it complicates the design and interpretation of clinical trials, high response rates for active and sham interventions indicate that we can achieve symptom relief in many patients and thus give them some reassurance. If indeed most therapies are only marginally better than placebo, the differences in adverse effects should be weighed more strongly, a point that is especially important in view of the controversy surrounding metoclopramide. Mechanistic studies introduced the network of macrophages as another potentially important player in the development of gastroparesis. Results are too preliminary and are largely based on preclinical data but show up- and downregulation of cellular elements controlling gastric function. Thus, future developments may teach us how they interfere with some of these mechanisms in clinical settings, potentially making gastroparesis a reversible process.
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Affiliation(s)
| | - Klaus Bielefeldt
- Division of Gastroenterology, University of Utah, UT, USA.,Gastroenterology Section, George E. Wahlen Department of Veterans Affairs Medical Center, 500 Foothill Drive, Salt Lake City, UT 84103, USA
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42
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The Investigation and Treatment of Diabetic Gastroparesis. Clin Ther 2018; 40:850-861. [PMID: 29748143 DOI: 10.1016/j.clinthera.2018.04.012] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 04/05/2018] [Accepted: 04/17/2018] [Indexed: 12/17/2022]
Abstract
PURPOSE This review provides an update on the investigations and treatment options for gastroparesis. METHODS A comprehensive literature search of Medline, PubMed, Embase and OVID was conducted which included all systematic reviews and research articles that focused on the diagnosis, investigations and management diabetic gastroparesis. FINDINGS Dietary modifications and pharmacologic treatment with prokinetics to increase gastric motility form the mainstay of treatment. However, the use of prokinetics is limited by adverse effects and serious adverse effects, leaving metoclopramide as the only drug approved by the US Food and Drug Administration for the treatment of gastroparesis. Newer therapies, including motilin receptor agonists, ghrelin receptor agonists, and neurokinin receptor antagonists, are currently being investigated. Transpyloric stenting, gastric electrical stimulation, and gastric per-oral endoscopic myotomy provide mechanical options for intervention, and surgical interventions in severe intractable gastroparesis include laparoscopic pyloroplasty or gastrectomy. IMPLICATIONS Advances to better understand the pathophysiology and management of diabetic gastroparesis have been limited, especially with discordance between symptoms and severity of delay in gastric emptying. Established treatment options are limited; however, recent pharmacologic and surgical interventions show promise.
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Saadi M, Yu D, Malik Z, Parkman HP, Schey R. Pyloric sphincter characteristics using EndoFLIP ® in gastroparesis. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2018; 83:375-384. [PMID: 29709494 DOI: 10.1016/j.rgmx.2018.02.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 01/19/2018] [Accepted: 02/02/2018] [Indexed: 12/12/2022]
Abstract
INTRODUCTION AND AIMS Pyloric sphincter abnormalities may be detected in gastroparesis. Botulinum toxin A (BoNT/A) injection into the pylorus has been used to treat gastroparesis with varying results. The aim of the present article was to assess whether pyloric sphincter characteristics using the endoscopic functional lumen imaging probe (EndoFLIP®) with impedance planimetry in patients with gastroparesis correlated with symptoms, gastric emptying, and therapeutic response to pyloric sphincter BoNT/A injection. METHODS EndoFLIP® study was performed on patients undergoing gastroparesis treatment with BoNT/A. The gastroparesis cardinal symptom index (GCSI) was applied prior to treatment and at post-treatment weeks 2, 4, 8, and 12. RESULTS Forty-four patients were enrolled (30 with idiopathic gastroparesis, 14 with diabetic gastroparesis). Smaller pyloric diameter, cross-sectional area (CSA), and distensibility correlated with worse vomiting and retching severity at baseline. Greater gastric retention tended to correlate with decreased CSA and pyloric distensibility. BoNT/A treatment resulted in a significant decrease in the GCSI score at 2 and 4 weeks after treatment, but not at post-treatment weeks 8 or 12. Nausea, early satiety, postprandial fullness, and upper abdominal pain improved up to 12 weeks, whereas loss of appetite, stomach fullness, and stomach visibly larger improved only up to 4 weeks. Retching and vomiting failed to improve. Greater pyloric compliance at baseline correlated with greater improvement in early satiety and náusea at 8 weeks and greater pyloric distensibility correlated with improvement in upper abdominal pain. CONCLUSIONS EndoFLIP® characteristics of the pylorus provided important pathophysiologic information in patients with gastroparesis, in relation to symptoms, gastric emptying, and predicting the response to treatment directed at the pylorus.
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Affiliation(s)
- M Saadi
- Área de Gastroenterología, Departamento de Medicina, Temple University School of Medicine, Filadelfia, PA, Estados Unidos
| | - D Yu
- Temple Clinical Research Institute, Departamento de Ciencias Clínicas, Temple University School of Medicine, Filadelfia, PA, Estados Unidos
| | - Z Malik
- Área de Gastroenterología, Departamento de Medicina, Temple University School of Medicine, Filadelfia, PA, Estados Unidos
| | - H P Parkman
- Área de Gastroenterología, Departamento de Medicina, Temple University School of Medicine, Filadelfia, PA, Estados Unidos
| | - R Schey
- Área de Gastroenterología, Departamento de Medicina, Temple University School of Medicine, Filadelfia, PA, Estados Unidos.
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Abstract
PURPOSE OF REVIEW Gastroparesis remains a difficult-to-treat disease with limited therapeutic options. Though patients often have a common syndrome of stereotypic symptoms, the underlying pathophysiology is heterogeneous, often leading to variable treatment responses. Due to limitations in medical and surgical therapies, endoscopic options have been increasingly explored. These options can be broadly categorized into pyloric-directed therapy, non-pyloric-directed therapy, and nutritional support. In this review, we will highlight current and emerging endoscopic options, such as gastric per-oral endoscopic myotomy (G-POEM). RECENT FINDINGS Early retrospective studies on G-POEM offer encouraging results up to one year out, with an acceptable safety profile. Other pyloric-directed therapies, such as pyloric dilation and stenting, have also been explored. While emerging endoscopic therapeutic options are encouraging, efficacy will likely depend on a better characterization of underlying pathophysiology and improved patient selection. Future prospective, controlled studies are needed.
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Affiliation(s)
- Andrew Su
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, 10945 Le Conte Avenue, Suite 2114, Los Angeles, CA, 90095, USA.
| | - Jeffrey L Conklin
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, 10945 Le Conte Avenue, Suite 2114, Los Angeles, CA, 90095, USA.,Gastrointestinal Motor Function Laboratory, UCLA, Los Angeles, CA, USA
| | - Alireza Sedarat
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, 10945 Le Conte Avenue, Suite 2114, Los Angeles, CA, 90095, USA
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Gilsdorf D, Volckmann E, Brickley A, Taylor LJ, Glasgow RE, Fang J. Pyloroplasty Offers Relief of Postfundoplication Gastroparesis in Patients Who Improved After Botulinum Toxin Injection. J Laparoendosc Adv Surg Tech A 2017; 27:1180-1184. [DOI: 10.1089/lap.2017.0099] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Daniel Gilsdorf
- Divisions of Gastroenterology and General Surgery, University of Utah Hospital, Salt Lake City, Utah
| | - Eric Volckmann
- Divisions of Gastroenterology and General Surgery, University of Utah Hospital, Salt Lake City, Utah
| | - Abbie Brickley
- Divisions of Gastroenterology and General Surgery, University of Utah Hospital, Salt Lake City, Utah
| | - Linda Jo Taylor
- Divisions of Gastroenterology and General Surgery, University of Utah Hospital, Salt Lake City, Utah
| | - Robert E. Glasgow
- Divisions of Gastroenterology and General Surgery, University of Utah Hospital, Salt Lake City, Utah
| | - John Fang
- Divisions of Gastroenterology and General Surgery, University of Utah Hospital, Salt Lake City, Utah
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Gonzalez JM, Benezech A, Vitton V, Barthet M. G-POEM with antro-pyloromyotomy for the treatment of refractory gastroparesis: mid-term follow-up and factors predicting outcome. Aliment Pharmacol Ther 2017; 46:364-370. [PMID: 28504312 DOI: 10.1111/apt.14132] [Citation(s) in RCA: 121] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 02/21/2017] [Accepted: 04/13/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND Gastric peroral endoscopic pyloromyotomy (G-POEM) was introduced for treating refractory gastroparesis. AIM To present a series of patients focussed on clinical mid-term efficacy and predictive outcomes factors. METHODS This was a single centre study of 29 patients operated on between January 2014 and April 2016, with disturbed gastric emptying scintigraphy (GES) and/or elevated Gastroparesis Cardinal Symptoms Index (GCSI). The procedures were performed as previously described. The primary endpoint was the efficacy at 3 and 6 months, based on GCSI and symptoms. The secondary endpoints were GES evolution, procedure reproducibility and safety, and identification of predictive factors for success. RESULTS There were 10 men, 19 women (mean age 52.8±18). The technical success rate was 100% (average 47 minutes). There were two complications managed conservatively: one bleeding and one abscess. The median follow-up was 10±6.4 months. The clinical success rate was 79% at 3 months, 69% at 6 months, with a significant decrease in the mean GCSI compared to pre-operatively (3.3±0.9 vs 1±1.2 and 1.1±0.9 respectively). The GES (n=23) normalised in 70% of cases, with a significant improvement of the mean half emptying time and retention at 2 hours, and a discordance in 21% of the cases. In univariate analysis, diabetes and female gender were significantly associated with risk of failure, but not confirmed in multivariate analysis. CONCLUSIONS The mid-term efficacy of G-POEM reaches 70% at 6 months. The procedure remains reproducible and safe. Diabetes and female gender were predictive of failure.
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Affiliation(s)
- J M Gonzalez
- Service de Gastro-entérologie, Hôpital Nord, APHM, Aix Marseille Université, Marseille, France
| | - A Benezech
- Service de Gastro-entérologie, Hôpital Nord, APHM, Aix Marseille Université, Marseille, France
| | - V Vitton
- Service de Gastro-entérologie, Hôpital Nord, APHM, Aix Marseille Université, Marseille, France
| | - M Barthet
- Service de Gastro-entérologie, Hôpital Nord, APHM, Aix Marseille Université, Marseille, France
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Mowzoon M, Macedo FIB, Kaur J, Kolachalam R. Effectiveness and feasibility of robotic gastric neurostimulator placement in patients with refractory gastroparesis. J Robot Surg 2017; 12:303-310. [PMID: 28730536 DOI: 10.1007/s11701-017-0732-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 07/15/2017] [Indexed: 12/17/2022]
Abstract
Gastric neurostimulation (GNS) with Enterra® therapy device (Medtronic, Minneapolis, MN) appears as the last resort for patients with refractory gastroparesis. Currently, the device has Humanitarian Use status by Food and Drug Administration, thereby requiring further investigation. We aim to describe its feasibility and clinical outcomes using robotic technique. From June 2014 to September 2016, 15 consecutive patients underwent robotic insertion of Enterra® device. Patient demographics, comorbidities, and clinical outcomes including mortality, length of stay, readmission rates, reoperation and complications were retrospectively collected. Patients were also assessed based on a validated 14-point questionnaire regarding satisfaction with the operation, quality of life and symptomatic relief. Mean age was 41.6 years ± 13.8 and there were 11 females (73.3%). No mortality was reported. The annual hospital admissions were reduced after GNS (2.5 ± 4.1 vs. 3.6 ± 4.4, p = 0.004). The frequency of bloating (p = 0.029) and severity of emesis (p = 0.038), early satiety (p = 0.042) and bloating (p = 0.031) were reduced after GNS. The severity and frequency total scores were also improved after GNS (12.6 ± 1.4 vs. 18.1 ± 2.7, p = 0.008 and 12.9 ± 2.2 vs. 16.1 ± 1.1, p = 0.016, respectively). This is the first report describing the clinical experience with robotic insertion of GNS device. This approach is safe and feasible and seems to have similar long-term outcomes as laparoscopic technique. Potential advantages to robotic technique include enhanced dexterity and suturing of the device within gastric wall. Further experience with large prospective studies and randomized clinical trials may be warranted.
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Affiliation(s)
- Mia Mowzoon
- Department of Surgery, Providence Hospital and Medical Centers, Michigan State University College of Human Medicine, 16001 W Nine Mile Rd, Southfield, MI, 48075, USA
| | - Francisco Igor B Macedo
- Department of Surgery, Providence Hospital and Medical Centers, Michigan State University College of Human Medicine, 16001 W Nine Mile Rd, Southfield, MI, 48075, USA.
| | - Jaskiran Kaur
- Department of Surgery, Providence Hospital and Medical Centers, Michigan State University College of Human Medicine, 16001 W Nine Mile Rd, Southfield, MI, 48075, USA
| | - Ramachandra Kolachalam
- Department of Surgery, Providence Hospital and Medical Centers, Michigan State University College of Human Medicine, 16001 W Nine Mile Rd, Southfield, MI, 48075, USA
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Jiang G, Bai D, Qian J, Chen P, Jin S. Modified Laparoscopic Pyloroplasty During Laparoscopic Splenectomy and Azygoportal Disconnection for the Prevention of Postoperative Gastroparesis. Surg Innov 2017; 24:328-335. [PMID: 28689488 DOI: 10.1177/1553350617697186] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Gastroparesis is a common complication after splenectomy and azygoportal disconnection, remaining a chronic debilitating disorder with considerable treatment challenges. To minimize postoperative gastroparesis, we have developed a new modified laparoscopic pyloroplasty (LP) technique for use during laparoscopic splenectomy and azygoportal disconnection (LSD). METHODS We retrospectively evaluated the outcomes of 31 cirrhotic patients with portal hypertensive bleeding and secondary hypersplenism who underwent synchronous LSD with modified LP (n = 14) or LSD without modified LP (n = 17) between January 2015 and August 2015. Perioperative variables were compared. RESULTS LSD with and without modified LP were successful in all patients. Operation time was significantly longer for LSD with modified LP than LSD without modified LP ( P = .001). However, the LSD with modified LP group had significantly reduced incidences of bloating 1 month postoperatively ( P < .05), nausea ( P < .05), and bloating ( P < .05) 3 months postoperatively, gastric retention 3 months postoperatively ( P < .0001), and prokinetic use at 1 month ( P = .009) and 3 months postoperatively ( P < .05) compared with the LSD without modified LP group. Gastric emptying scintigraphy showed that the mean time required to empty 50% of the ingested meal was significantly shorter in the LSD with modified LP group than in the LSD without modified LP group at 3 months postoperatively (74.3 ± 19.1 vs 261.7 ± 61.0 minutes, P < .0001). CONCLUSIONS Modified LP during LSD was feasible, effective, and safe, and significantly reduced short-term symptoms of postoperative gastroparesis.
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Affiliation(s)
- Guoqing Jiang
- 1 Clinical Medical College of Yangzhou University, Yangzhou, Jiangsu Province, China
| | - Dousheng Bai
- 1 Clinical Medical College of Yangzhou University, Yangzhou, Jiangsu Province, China
| | - Jianjun Qian
- 1 Clinical Medical College of Yangzhou University, Yangzhou, Jiangsu Province, China
| | - Ping Chen
- 1 Clinical Medical College of Yangzhou University, Yangzhou, Jiangsu Province, China
| | - Shengjie Jin
- 1 Clinical Medical College of Yangzhou University, Yangzhou, Jiangsu Province, China
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Lee JH, Kim CG, Kim YW, Choi IJ, Lee JY, Cho SJ, Kim YI, Eom BW, Yoon HM, Ryu KW. Botulinum Toxin Injection for the Treatment of Delayed Gastric Emptying Following Pylorus-Preserving Gastrectomy: an Initial Experience. J Gastric Cancer 2017; 17:173-179. [PMID: 28680722 PMCID: PMC5489546 DOI: 10.5230/jgc.2017.17.e18] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Revised: 05/09/2017] [Accepted: 05/22/2017] [Indexed: 12/18/2022] Open
Abstract
Purpose To report our experience of endoscopic botulinum toxin injection in patients who experienced severe delayed gastric emptying after pylorus-preserving gastrectomy (PPG). Materials and Methods We reviewed the medical records of 6 patients who received the botulinum toxin injection. They presented with severe delayed gastric emptying in the early postoperative period. Endoscopic botulinum toxin was administered as 4 injections of 25−50 IU into each of the 4 quadrants of the prepyloric area. Results All botulinum toxin injections were successful without any complications, enabling 5 patients to tolerate soft solid diets and one to tolerate a soft fluid diet within 10 days. The endoscopic criteria of 4 patients improved. Symptom recurrence caused 2 patients to undergo repeat injections that were successful. The median follow-up period was 27 months, and all patients could ingest normal regular diets at the last follow-up. Conclusions Endoscopic botulinum toxin injection is a feasible treatment option for early delayed gastric emptying after PPG.
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Affiliation(s)
- Jung Hwan Lee
- Center for Gastric Cancer, National Cancer Center, Goyang, Korea
| | - Chan Gyoo Kim
- Center for Gastric Cancer, National Cancer Center, Goyang, Korea
| | - Young-Woo Kim
- Center for Gastric Cancer, National Cancer Center, Goyang, Korea
| | - Il Ju Choi
- Center for Gastric Cancer, National Cancer Center, Goyang, Korea
| | - Jong Yeul Lee
- Center for Gastric Cancer, National Cancer Center, Goyang, Korea
| | - Soo-Jeong Cho
- Center for Gastric Cancer, National Cancer Center, Goyang, Korea
| | - Young-Il Kim
- Center for Gastric Cancer, National Cancer Center, Goyang, Korea
| | - Bang Wool Eom
- Center for Gastric Cancer, National Cancer Center, Goyang, Korea
| | - Hong Man Yoon
- Center for Gastric Cancer, National Cancer Center, Goyang, Korea
| | - Keun Won Ryu
- Center for Gastric Cancer, National Cancer Center, Goyang, Korea
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Sanger GJ, Pasricha PJ. Investigational drug therapies for the treatment of gastroparesis. Expert Opin Investig Drugs 2017; 26:331-342. [PMID: 28127997 DOI: 10.1080/13543784.2017.1288214] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Gastroparesis is defined by nausea, vomiting, pain, early satiety and bloating, and characterized by delayed gastric emptying without obvious structural abnormalities. Metoclopramide is widely used, increasing gastric emptying and inhibiting nausea and vomiting. Other drugs are available in certain countries and some are used 'off-label' because they increase gastric emptying or inhibit emesis. However, correlation between gastroparesis symptoms and rates of gastric emptying is poor. For anti-emetic drugs, dose-ranging and Phase III trials in gastroparesis are lacking. Areas covered: Gastric motility may still be disordered, leading to nausea, even though gastric emptying is unchanged. One hypothesis is that interstitial cells of Cajal (ICC) are damaged by diabetes leading to gastric dysrhythmia and nausea. Novel approaches to treatment of nausea also include the use of ghrelin receptor agonists, highlighting a link between appetite and nausea. Expert opinion: There is an urgent need to diversify away from historical drug targets. In particular, there is a need to control nausea by regulating ICC functions and/or by facilitating appetite via ghrelin receptor agonists. It is also important to note that different upper gastrointestinal disorders (gastroparesis, chronic unexplained nausea and vomiting, functional dyspepsia) are difficult to distinguish apart, suggesting wider therapeutic opportunity.
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Affiliation(s)
- Gareth J Sanger
- a Professor of Neuropharmacology , Blizard Institute and the National Centre for Bowel Research, Barts The London School of Medicine and Dentistry, Queen Mary University of London , London , UK
| | - Pankaj Jay Pasricha
- b Vice Chair of Medicine for Innovation and Commercialization , Johns Hopkins University School of Medicine, Director, Johns Hopkins Center for Neurogastroenterology, Professor of Medicine and Neurosciences, Professor of Innovation Management, Johns Hopkins Carey School of Business , Baltimore , MD , USA
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