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Na HK, Li AA, Gottfried-Blackmore A, Podboy AJ, Esquivel MM, Joseph AA, Nguyen L, Hwang JH. Pyloric Dysfunction: A Review of the Mechanisms, Diagnosis, and Treatment. Gut Liver 2025; 19:327-345. [PMID: 40058793 PMCID: PMC12070220 DOI: 10.5009/gnl240421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2024] [Revised: 11/04/2024] [Accepted: 11/06/2024] [Indexed: 05/14/2025] Open
Abstract
Pyloric dysfunction is defined as hypertonia or spasm of the pyloric sphincter. The pylorus plays a key role in gastric emptying, but its function remains incompletely understood. Most studies have focused on gastroparesis regardless of the underlying pathophysiology. Few studies have reported pyloric dysfunction in patients with gastroparesis, and the diagnostic and treatment modalities for pyloric dysfunction are not well established. Recently developed diagnostic modalities assessing pyloric function, such as high-resolution antroduodenal manometry and endoluminal functional lumen imaging, are currently being evaluated. A variety of therapeutic interventions targeting the pylorus, including pharmacologic agents, intrapyloric botulinum injection, endoscopic balloon dilation, stent insertion, surgical pyloroplasty, and gastric peroral endoscopic pyloromyotomy, have been proposed. Among these, gastric peroral endoscopic pyloromyotomy has emerged as a novel, minimally invasive therapy with demonstrated efficacy and safety for refractory gastroparesis. This article reviews the pathophysiology of pyloric dysfunction and the potential diagnostic and therapeutic modalities based on the latest literature.
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Affiliation(s)
- Hee Kyong Na
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Andrew A. Li
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Andres Gottfried-Blackmore
- Department of Pharmacology and Division of Gastroenterology, Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Alexander J. Podboy
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, VA, USA
| | - Micaela M. Esquivel
- Division of General Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Abel A. Joseph
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Linda Nguyen
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Joo Ha Hwang
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Division of General Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
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Malagelada C, Keller J, Sifrim D, Serra J, Tack J, Mulak A, Stengel A, Aguilar A, Drewes AM, Josefsson A, Bonaz B, Dumitrascu D, Keszthelyi D, Barba E, Carbone F, Zerbib F, Marchegiani G, Hauser G, Gourcerol G, Tornblom H, Hammer H, Aziz I, Matic JR, Mendive J, Nikaki K, Wauters L, Alcalá‐González LG, Waluga M, Jinga M, Corsetti M, Rommel N, Shidrawi R, De Giorgio R, Kadirkamanathan S, Surdea‐Blaga T. European Guideline on Chronic Nausea and Vomiting-A UEG and ESNM Consensus for Clinical Management. United European Gastroenterol J 2025; 13:427-471. [PMID: 39754724 PMCID: PMC11999049 DOI: 10.1002/ueg2.12711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 09/03/2024] [Accepted: 09/04/2024] [Indexed: 01/06/2025] Open
Abstract
INTRODUCTION Chronic nausea and vomiting are symptoms of a wide range of gastrointestinal and non-gastrointestinal conditions. Diagnosis can be challenging and requires a systematic and well-structured approach. If the initial investigation for structural, toxic and metabolic disorders is negative, digestive motility and gut-brain interaction disorders should be assessed. United European Gastroenterology (UEG) and the European Society for Neurogastroenterology and Motility (ESNM) identified the need for an updated, evidence-based clinical guideline for the management of chronic nausea and vomiting. METHODS A multidisciplinary team of experts in the field, including European specialists and national societies, participated in the development of the guideline. Relevant questions were addressed through a literature review and statements were developed and voted on according to a Delphi process. RESULTS Ninety-eight statements were identified and voted following the Delphi process. Overall agreement was high, although the grade of scientific evidence was low in many areas. Disagreement was more evident for some pharmacological treatment options. A diagnostic algorithm was developed, focussing on the differentiating features between gastrointestinal motility and gut-brain interaction disorders with predominant nausea and vomiting. CONCLUSION These guidelines provide an evidence-based framework for the evaluation and treatment of patients with chronic nausea and vomiting.
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Yang DY, Camilleri M. The goals for successful development of treatment in gastroparesis. Neurogastroenterol Motil 2024; 36:e14849. [PMID: 38884392 DOI: 10.1111/nmo.14849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 04/10/2024] [Accepted: 06/05/2024] [Indexed: 06/18/2024]
Abstract
BACKGROUND Gastroparesis is a motility disorder of the stomach characterized by cardinal symptoms and delayed gastric emptying of solid food in the absence of mechanical obstruction. There is significant unmet need in its management, and essentially there are no medications approved for its treatment over four decades. PURPOSE The objectives of this review are to develop an understanding of the goals of treatment, the evidence-based criteria for treatment success based on the current scientific understanding of gastroparesis as well as patient response outcomes, and to propose evidence-based principles for the successful development of treatments for gastroparesis. Specifically, we discuss the pathophysiologic targets in gastroparesis, eligibility criteria for clinical trial participation based on validated gastric emptying studies, and the patient response outcome measures that have been validated to appraise effects of treatment on clinically relevant outcomes. These considerations lead to recommendations regarding eligibility, design, and duration of proof-of-efficacy studies, and to endorsing the American Neurogastroenterology and Motility Society Gastroparesis Cardinal Symptom Index Daily Diary as a validated patient response outcome and to justification of the shortening of proof-of-efficacy, placebo-controlled clinical trials to 4 weeks treatment duration after a baseline period. We believe that such approaches will increase the likelihood of successful assessment of efficacy of novel approaches to treating patients with gastroparesis.
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Affiliation(s)
- David Yi Yang
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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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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Soliman H, Wuestenberghs F, Desprez C, Leroi AM, Melchior C, Gourcerol G. Physiological characterization of gastric emptying using high-resolution antropyloroduodenal manometry. Am J Physiol Gastrointest Liver Physiol 2024; 326:G16-G24. [PMID: 37874655 DOI: 10.1152/ajpgi.00101.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 10/12/2023] [Accepted: 10/23/2023] [Indexed: 10/26/2023]
Abstract
Delayed gastric emptying (GE) has been associated with antral and pyloric dysmotility. We aimed to characterize differences in the antral, duodenal, and pyloric motility profiles associated with delayed GE, using high-resolution antropyloroduodenal manometry (HR-ADM). Patients referred for HR-ADM for dyspeptic symptoms performed a concurrent GE breath test (NCT01519180 and NCT04918329). HR-ADM involved 36 sensors 1 cm apart, placed across the pylorus. Interdigestive and postprandial periods were identified. Antral, pyloric, and duodenal motor profiles were analyzed recording the frequency, amplitude, and propagative nature of contractions for each period. Plots of patients with normal and delayed GE were compared. Sixty patients underwent both HR-ADM and GE tests. Twenty-five and 35 patients had delayed and normal GE, respectively. Antral and duodenal motor profiles were not different between the two groups during the interdigestive period. During the postprandial period, a lower frequency of antral contractions was associated with delayed GE (2.22 vs. 1.39 contractions/min; P = 0.002), but no difference in mean contraction amplitude was observed. The pyloric region was identified in all the patients and pylorospasms, defined as 3 min of repeated isolated pyloric contractions, were more frequent in patients with delayed GE (32.0% vs. 5.7%; P = 0.02) during the postprandial period. No difference in duodenal contraction profiles was observed. Manometric profile alterations were observed in 72% of the patients with delayed GE, with 56% having a low frequency of antral contractions. Using HR-ADM, patients with delayed GE displayed different postprandial antropyloric motility as compared with patients with normal GE.NEW & NOTEWORTHY High-resolution antropyloroduodenal manometry (HR-ADM) allows precise characterization of antral, pyloric, and duodenal motility, although its association with gastric emptying (GE) has been poorly investigated. Concurrent HR-ADM with GE measurement showed a lower frequency of antral postprandial contractions and an increased frequency of postprandial pylorospasms in patients with delayed GE. HR-ADM could, therefore, be useful in the future to better select patients for treatments targeting the pylorus.
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Affiliation(s)
- Heithem Soliman
- Department of Physiology, Université Rouen Normandie, INSERM, ADEN UMR1073, "Nutrition, Inflammation and Microbiota-Gut-Brain Axis," CHU Rouen, Rouen, France
- Department of Gastroenterology, Université de Paris-Cité, Hôpital Louis Mourier, Colombes, France
| | - Fabien Wuestenberghs
- Department of Physiology, Université Rouen Normandie, INSERM, ADEN UMR1073, "Nutrition, Inflammation and Microbiota-Gut-Brain Axis," CHU Rouen, Rouen, France
- Department of Gastroenterology, Hôpital Avicenne, Sorbonne Paris Nord University, Bobigny, France
| | - Charlotte Desprez
- Department of Physiology, Université Rouen Normandie, INSERM, ADEN UMR1073, "Nutrition, Inflammation and Microbiota-Gut-Brain Axis," CHU Rouen, Rouen, France
| | - Anne-Marie Leroi
- Department of Physiology, Université Rouen Normandie, INSERM, ADEN UMR1073, "Nutrition, Inflammation and Microbiota-Gut-Brain Axis," CHU Rouen, Rouen, France
| | - Chloé Melchior
- Department of Gastroenterology, Université Rouen Normandie, INSERM, ADEN UMR1073, "Nutrition, Inflammation and Microbiota-Gut-Brain Axis," CHU Rouen, Rouen, France
| | - Guillaume Gourcerol
- Department of Physiology, Université Rouen Normandie, INSERM, ADEN UMR1073, "Nutrition, Inflammation and Microbiota-Gut-Brain Axis," CHU Rouen, Rouen, France
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Vackova Z, Levenfus I, Pohl D. Interventional functional diagnostics in gastrointestinal endoscopy: Combining diagnostic and therapeutic tools in the endoscopy suite with the functional lumen imaging probe. Curr Opin Pharmacol 2023; 73:102414. [PMID: 38029641 DOI: 10.1016/j.coph.2023.102414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 10/18/2023] [Accepted: 11/03/2023] [Indexed: 12/01/2023]
Abstract
With technical progress of gastrointestinal functional testing, there has been a demand for more comprehensive examination of esophageal physiology and pathophysiology beyond high-resolution manometry. A new interventional technology based on impedance planimetry, the functional lumen imaging probe (FLIP), enables intraluminal measurement of distensibility and compliance of hollow organs. EndoFLIP uses balloon catheters to measure diameter and distension pressure to calculate cross-sectional area and distensibility in different organs (mostly esophagus, stomach, anorectal region) and can be used in wide variety of indications (diagnostics, pre- and post-treatment evaluation) and currently serves as a helpful adjunctive tool in ambiguous clinical cases. EsoFLIP is a therapeutic variation that uses a stiffer balloon catheter allowing for dilation. The trend to simplify the clinical process from diagnosis to treatment tends to a one-session procedure combining diagnostics and therapeutic interventions. In specified conditions like e.g. achalasia or gastroparesis, a combination of EndoFLIP and EsoFLIP procedures may therefore be useful. The aim of this narrative review is to introduce the clinical use of FLIP and its potential benefit in combined diagnostic-therapeutic procedures.
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Affiliation(s)
- Zuzana Vackova
- Department of Gastrointestinal Endoscopy, Department of Medicine, Military University Hospital Prague, Czech Republic.
| | - Ian Levenfus
- Division of Gastroenterology and Hepatology, University Hospital Zurich, Switzerland
| | - Daniel Pohl
- Division of Gastroenterology and Hepatology, University Hospital Zurich, Switzerland
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Razzak FA, Kerbage A, Brunaldi VO, Mrad R, Mahmoud T, Gala K, Vargas EJ, Storm A, Ghanem O, Dayyeh BA. Correlation Between Gastrojejunal Anastomosis Diameter, Distensibility Index, and Weight Regain After Roux-en-Y Gastric Bypass. Obes Surg 2023; 33:4042-4048. [PMID: 37922061 DOI: 10.1007/s11695-023-06918-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 10/17/2023] [Accepted: 10/18/2023] [Indexed: 11/05/2023]
Abstract
INTRODUCTION Gastrojejunal anastomosis (GJA) dilation is an independent predictor of weight regain (WR) after Roux-en-Y gastric bypass (RYGB). However, the role of planimetric measurements in this context remains unknown. METHODS This is a retrospective cohort study including adult RYGB patients who underwent a diagnostic endoscopy with Endoflip assessment of the GJA. We excluded patients in the early postoperative period and those with abnormal endoscopic findings (marginal ulcers and gastro-gastric fistulas). RESULTS Thirty-four patients were initially included. Endoscopic GJA diameter had a moderate positive correlation with WR (r=+0.438, p=0.011). However, after excluding the 7 patients with GJA> 30 mm, there was no significant correlation. There was a moderate agreement between the EndoFLIP-GJA diameter at 60mL and endoscopic diameter (ICC=0.576, p=0.049). The distensibility index (DI) showed a consistent moderate negative correlation with WR. Considering the maximum DI at 40 ml, we found a cutoff of DI = 7 mm2/mmHg that split the sample in two significantly different populations in terms of WR (67.4% vs. 43.2%, p=0.04). CONCLUSION Visual estimation of the GJA diameter correlates with EndoFLIP at 60mL. In the subset of patients with GJA ≤ 30 mm, more distensible GJAs are associated with lower rates of WR. Larger studies are needed to confirm this correlation and to validate its utility for clinical management.
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Affiliation(s)
- Farah Abdul Razzak
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street Southwest, Rochester, Rochester, MN, 55905, USA
| | - Anthony Kerbage
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street Southwest, Rochester, Rochester, MN, 55905, USA
| | - Vitor O Brunaldi
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street Southwest, Rochester, Rochester, MN, 55905, USA
- Gastroenterology Department, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Rudy Mrad
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street Southwest, Rochester, Rochester, MN, 55905, USA
| | - Tala Mahmoud
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street Southwest, Rochester, Rochester, MN, 55905, USA
| | - Khushboo Gala
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street Southwest, Rochester, Rochester, MN, 55905, USA
| | - Eric J Vargas
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street Southwest, Rochester, Rochester, MN, 55905, USA
| | - Andrew Storm
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street Southwest, Rochester, Rochester, MN, 55905, USA
| | - Omar Ghanem
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Barham Abu Dayyeh
- Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street Southwest, Rochester, Rochester, MN, 55905, USA.
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White E, Mutalib M. Use of endolumenal functional lumen imaging probe in investigating paediatric gastrointestinal motility disorders. World J Clin Pediatr 2023; 12:162-170. [PMID: 37753495 PMCID: PMC10518749 DOI: 10.5409/wjcp.v12.i4.162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 08/09/2023] [Accepted: 08/23/2023] [Indexed: 09/06/2023] Open
Abstract
Investigating gastrointestinal (GI) motility disorders relies on diagnostic tools to assess muscular contractions, peristalsis propagation and the integrity and coordination of various sphincters. Manometries are the gold standard to study the GI motor function but it is increasingly acknowledged that manometries do not provide a complete picture in relation to sphincters competencies and muscle fibrosis. Endolumenal functional lumen imaging probe (EndoFLIP) an emerging technology, uses impedance planimetry to measure hollow organs cross sectional area, distensibility and compliance. It has been successfully used as a complementary tool in the assessment of the upper and lower oesophageal sphincters, oesophageal body, the pylorus and the anal canal. In this article, we aim to review the uses of EndoFLIP as a tool to investigate GI motility disorders with a special focus on paediatric practice. The majority of EndoFLIP studies were conducted in adult patients but the uptake of the technology in paediatrics is increasing. EndoFLIP can provide a useful complementary data to the existing GI motility investigation in both children and adults.
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Affiliation(s)
- Emily White
- Department of Paediatric Gastroenterology, Evelina London Children’s Hospital, London SE1 7EH, United Kingdom
| | - Mohamed Mutalib
- Department of Paediatric Gastroenterology, Evelina London Children’s Hospital, London SE1 7EH, United Kingdom
- Faculty of Life Sciences and Medicine, King’s College London, London SE1 7EH, United Kingdom
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Rossi RE, Elvevi A, Sciola V, Mandarino FV, Danese S, Invernizzi P, Massironi S. Paradoxical association between dyspepsia and autoimmune chronic atrophic gastritis: Insights into mechanisms, pathophysiology, and treatment options. World J Gastroenterol 2023; 29:3733-3747. [PMID: 37398891 PMCID: PMC10311608 DOI: 10.3748/wjg.v29.i23.3733] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 04/23/2023] [Accepted: 05/06/2023] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND Autoimmune gastritis (AIG) is a progressive, chronic, immune-mediated inflammatory disease characterized by the destruction of gastric parietal cells leading to hypo/anacidity and loss of intrinsic factor. Gastrointestinal symptoms such as dyspepsia and early satiety are very common, being second in terms of frequency only to anemia, which is the most typical feature of AIG. AIM To address both well-established and more innovative information and knowledge about this challenging disorder. METHODS An extensive bibliographical search was performed in PubMed to identify guidelines and primary literature (retrospective and prospective studies, systematic reviews, case series) published in the last 10 years. RESULTS A total of 125 records were reviewed and 80 were defined as fulfilling the criteria. CONCLUSION AIG can cause a range of clinical manifestations, including dyspepsia. The pathophysiology of dyspepsia in AIG is complex and involves changes in acid secretion, gastric motility, hormone signaling, and gut microbiota, among other factors. Managing dyspeptic symptoms of AIG is challenging and there are no specific therapies targeting dyspepsia in AIG. While proton pump inhibitors are commonly used to treat dyspepsia and gastroesophageal reflux disease, they may not be appropriate for AIG. Prokinetic agents, antidepressant drugs, and non-pharmacological treatments may be of help, even if not adequately evidence-based supported. A multidisciplinary approach for the management of dyspepsia in AIG is recommended, and further research is needed to develop and validate more effective therapies for dyspepsia.
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Affiliation(s)
- Roberta Elisa Rossi
- Gastroenterology and Endoscopy Unit, IRCCS Humanitas Research Hospital, Rozzano 20089, Milan, Italy
| | - Alessandra Elvevi
- Gastroenterology Unit, Fondazione IRCCS San Gerardo dei Tintori, Monza 20900, Italy and Department of Medicine and Surgery, University of Milano-Bicocca, Monza 20900, Italy
| | - Valentina Sciola
- Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano 20100, Italy
| | | | - Silvio Danese
- Department of Gastroenterology and Endoscopy, IRCCS Ospedale San Raffaele, Milan 20132, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan 20132, Italy
| | - Pietro Invernizzi
- Gastroenterology Unit, Fondazione IRCCS San Gerardo dei Tintori, Monza 20900, Italy and Department of Medicine and Surgery, University of Milano-Bicocca, Monza 20900, Italy
| | - Sara Massironi
- Gastroenterology Unit, Fondazione IRCCS San Gerardo dei Tintori, Monza 20900, Italy and Department of Medicine and Surgery, University of Milano-Bicocca, Monza 20900, Italy
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Abstract
INTRODUCTION Gastroparesis is characterized by symptoms suggesting gastric retention of food and objective evidence of delayed gastric emptying in the absence of a mechanical obstruction. Nausea, vomiting, early satiety, and postprandial fullness are the classic symptoms of gastroparesis. Gastroparesis is increasingly encountered by physicians. There are several recognized etiologies of gastroparesis, including diabetic, post-surgical, medication-induced, post-viral, and idiopathic. AREAS COVERED A comprehensive literature review was conducted to identify studies discussing gastroparesis management. Dietary modifications, medication adjustments, glucose control, antiemetic agents, and prokinetic agents are all part of gastroparesis management. In this manuscript, we detail treatments evolving for gastroparesis, including nutritional, pharmaceutical, device, and recent advanced endoscopic and surgical therapies. This manuscript concludes with a speculative viewpoint on how the field will evolve in 5 years' time. EXPERT OPINION Identification of the dominant symptoms (fullness, nausea, abdominal pain, and heartburn) helps to direct management efforts of the patients. Treatments for refractory (treatment resistant) symptoms may include gastric electric stimulation and intra-pyloric interventions like botulinum toxin and endoscopic pyloromyotomy. Understanding the pathophysiology of gastroparesis, relating pathophysiologic abnormalities to specific symptoms, new efficacious pharmacotherapies, and better understanding of the clinical predictors of response of therapies, are priorities for future research in the field of gastroparesis.
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Affiliation(s)
- Maan El Halabi
- GI Motility Fellow, Section of Gastroenterology, Temple University Hospital, Philadelphia, PA, USA
| | - Henry P Parkman
- Professor of Medicine, Director of GI Motility Laboratory, Section of Gastroenterology, Temple University Hospital, Philadelphia, PA, USA
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Koch KL, Van Natta M, Parkman HP, Grover M, Abell TL, McCallum RW, Shaltout HA, Sarosiek I, Farrugia G, Shulman RJ, Tonascia J, Miriel L, Hamilton F. Effect of liquid and solid test meals on symptoms and gastric myoelectrical activity in patients with gastroparesis and functional dyspepsia. Neurogastroenterol Motil 2023; 35:e14376. [PMID: 35411675 PMCID: PMC9884454 DOI: 10.1111/nmo.14376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 03/06/2022] [Accepted: 03/14/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND Patients with gastroparesis (GP) and functional dyspepsia (FD) have similar symptoms, but the pathophysiology of postprandial symptoms remains uncertain. AIMS To compare symptoms and gastric myoelectrical activity (GMA) after liquid and solid test meals in patients with GP and FD. METHODS Patients enrolled in the Gastroparesis Clinical Research Consortium Registry were studied. Clinical characteristics were measured with standard questionnaires. GP was determined by 4-h solid-phase gastric scintigraphy. GMA was measured using electrogastrography before and after ingestion of a water load or nutrient bar on separate days. Symptoms were measured on visual analog scales. GMA responses to the water load for individual patients were also determined. RESULTS 284 patients with GP and 113 with FD were identified who ingested both test meals. Patients with GP and FD had similar maximal tolerated volumes of water [mean (SD) 378 (218) ml vs. 402 (226) ml, p = 0.23] and reported similar intensity of fullness, nausea, bloating, and abdominal discomfort after the test meals. Twenty-six percent and 19% of the patients with GP and FD, respectively, ingested subthreshold (<238 ml) volumes of water (p = 0.15). Gastric dysrhythmias were recorded in 66% of the GP and 65% of the FD patients after the water load. Symptoms and GMA were similar in both groups after ingestion of the nutrient bar. CONCLUSION The similarity in GMA responses and symptoms after ingestion of solid or liquid test meals suggests GP and FD are closely related gastric neuromuscular disorders.
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Affiliation(s)
- Kenneth L. Koch
- Section on Gastroenterology, Wake Forest University, Winston-Salem, NC
| | - Mark Van Natta
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Henry P. Parkman
- Section of Gastroenterology, Temple University, Philadelphia, PA
| | | | - Thomas L. Abell
- Digestive and Liver Health, University of Louisville, Louisville, KY
| | | | - Hossam A. Shaltout
- Cardiovascular Sciences Center, Wake Forest University, Winston-Salem, NC
| | - Irene Sarosiek
- Division of Gastroenterology, Texas Tech University, El Paso, TX
| | - Gianrico Farrugia
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Robert J. Shulman
- Children’s Nutrition Research Center, Baylor College of Medicine, Houston, TX
| | - James Tonascia
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Laura Miriel
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Frank Hamilton
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD
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Soliman H, Gourcerol G. Targeting the pylorus in gastroparesis: From physiology to endoscopic pyloromyotomy. Neurogastroenterol Motil 2023; 35:e14529. [PMID: 36594414 PMCID: PMC10077918 DOI: 10.1111/nmo.14529] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 08/28/2022] [Accepted: 12/19/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND The pylorus plays a key role in the control of gastric content outflow. Impairment of pyloric physiology has been observed in gastroparesis, particularly when associated with diabetes mellitus or opioid intake or after antireflux surgery. New tools have been developed to identify pyloric dysfunction in routine care, including functional luminal impedance planimetry (FLIP). As such, a new therapeutic strategy targeting the pylorus, namely endoscopic pyloromyotomy (G-POEM), has received increasing attention and emerged as a promising treatment for gastroparesis. PURPOSE The present review details the involvement of the pyloric pathophysiology in gastroparesis, as well as clinical results of G-POEM according to the current literature.
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Affiliation(s)
- Heithem Soliman
- Physiology Department, INSERM UMR 1073, CIC-CRB 1404, Centre Hospitalo-Universitaire de Rouen, Rouen, France.,Département d'Hépato-Gastro-Entérologie, Hôpital Louis Mourier, AP-HP Nord, Université de Paris Cité, Colombes, France
| | - Guillaume Gourcerol
- Physiology Department, INSERM UMR 1073, CIC-CRB 1404, Centre Hospitalo-Universitaire de Rouen, Rouen, France
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13
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Schwalbe K, Finelli C, Moon S, Niehaus H, Kondajji A, Tu C, Fathalizadeh A, Kroh M, Allemang M. Endoscopic findings do not predict per-oral pyloromyotomy (POP) response. Surg Endosc 2023; 37:1384-1391. [PMID: 35608698 DOI: 10.1007/s00464-022-09321-8] [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: 03/23/2022] [Accepted: 04/27/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Gastroparesis is a life-altering diagnosis caused by the stomach's inability to function in the absence of a mechanical obstruction. The primary causes are idiopathic, diabetic, and postoperative. Our first-line treatment for medical refractory gastroparesis is the endoscopic per-oral pyloromyotomy (POP) procedure. Predicting clinical response cost effectively remains elusive. METHODS All patients who underwent a POP procedure at our institution by a single surgical endoscopist from January 1, 2019 to June 30, 2020 were retrospectively reviewed. All endoscopic data were prospectively collected. The patients were followed by a survey including the Gastroparesis Cardinal Symptom Index (GCSI) and other relevant postoperative measures. The primary endpoint was clinical response defined as ≥ 1.0 decrease in the GCSI from preoperative to the time of survey. Secondary outcome was normalization of the gastric emptying study (GES). RESULTS Our patient population is 85% female and has an average age of 44.8 years. The diagnosis of gastroparesis is 71% iatrogenic, 19% postoperative, and 10% diabetic. On endoscopy, 30% had bile in the stomach and 65% had any degree of pylorospasm. The primary outcome measure of clinical response was 39% at an average of 697 ± 151 days post-POP, but 66% of patients attested to an improvement in their symptoms. Of 68 postoperative gastric emptying studies 50% normalized at an average of 145 ± 98 days. Following univariate and multivariate analyses of preoperative data and endoscopic findings, there were no significant predictors of clinical response. A preoperative GCSI ≥ 2.6 trends toward significance (OR 6.87, p = 0.058). CONCLUSION Endoscopic findings at the time of POP do not correlate with clinical response. The GCSI model currently used to measure clinical response may not accurately capture the full clinical picture. The long-term durability of endoscopic myotomy to treat medical refractory gastroparesis needs to be studied further to improve patient selection.
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Affiliation(s)
- Kathryn Schwalbe
- Cleveland Clinic-South Pointe Hospital, 20000 Harvard Road, Warrensville Heights, OH, 44122, USA.
| | - Caitlin Finelli
- Cleveland Clinic-South Pointe Hospital, 20000 Harvard Road, Warrensville Heights, OH, 44122, USA
| | - Soon Moon
- Cleveland Clinic-South Pointe Hospital, 20000 Harvard Road, Warrensville Heights, OH, 44122, USA
| | - Hannah Niehaus
- Cleveland Clinic-South Pointe Hospital, 20000 Harvard Road, Warrensville Heights, OH, 44122, USA
| | - Abhiram Kondajji
- Cleveland Clinic-South Pointe Hospital, 20000 Harvard Road, Warrensville Heights, OH, 44122, USA
| | - Chao Tu
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | | | - Matthew Kroh
- Digestive Disease and Surgical Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Matthew Allemang
- Cleveland Clinic-South Pointe Hospital, 20000 Harvard Road, Warrensville Heights, OH, 44122, USA
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14
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Noh JH, Jung HY. Role of Endoscopy in Motility Disorders of Upper Gastrointestinal Tract. J Neurogastroenterol Motil 2023; 29:7-19. [PMID: 36606432 PMCID: PMC9837547 DOI: 10.5056/jnm22170] [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: 10/05/2022] [Accepted: 12/19/2022] [Indexed: 01/07/2023] Open
Abstract
Gastrointestinal motility disorders have a wide range of symptoms and affect patients' quality of life. With the advancement of endoscopy, the diagnostic and therapeutic roles of endoscopy in motility disorders is becoming more significant. Endoscopy is necessary to rule out possible organic diseases in patients with suspected motility disorders and provide significant clues for their diagnosis. Moreover, interventional endoscopy may be a primary or alternative treatment option for selected patients with motility disorders, and it is becoming a promising field as new therapeutic applications are developed and utilized for various motility disorders. This review may provide suitable indications for the use of endoscopy in diagnosing and treating motility disorders of the upper gastrointestinal tract.
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Affiliation(s)
- Jin Hee Noh
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hwoon-Yong Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea,Correspondence: Hwoon-Yong Jung, MD, PhD, Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea, Tel: +82-2-3010-3197, Fax: +82-2-476-0824, E-mail:
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15
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Assessment of pyloric sphincter physiology after Ivor-Lewis esophagectomy using an endoluminal functional lumen imaging probe. Surg Endosc 2022:10.1007/s00464-022-09714-9. [DOI: 10.1007/s00464-022-09714-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 10/11/2022] [Indexed: 12/04/2022]
Abstract
Abstract
Objective of the study
The most common functional complication after Ivor-Lewis esophagectomy is the delayed emptying of the gastric conduit (DGCE) for which several diagnostic tools are available, e.g. chest X-ray, upper esophagogastroduodenoscopy (EGD) and water-soluble contrast radiogram. However, none of these diagnostic tools evaluate the pylorus itself. Our study demonstrates the successful measurement of pyloric distensibility in patients with DGCE after esophagectomy and in those without it.
Methods and procedures
Between May 2021 and October 2021, we performed a retrospective single-centre study of all patients who had an oncological Ivor-Lewis esophagectomy and underwent our post-surgery follow-up programme with surveillance endoscopies and computed tomography scans. EndoFlip™ was used to perform measurements of the pylorus under endoscopic control, and distensibility was measured at 40 ml, 45 ml and 50 ml balloon filling.
Results
We included 70 patients, and EndoFlip™ measurement was feasible in all patients. Successful application of EndoFlip™ was achieved in all interventions (n = 70, 100%). 51 patients showed a normal postoperative course, whereas 19 patients suffered from DGCE. Distensibility proved to be smaller in patients with symptoms of DGCE compared to asymptomatic patients. For 40 ml, 45 ml and 50 ml, the mean distensibility was 6.4 vs 10.1, 5.7 vs 7.9 and 4.5 vs 6.3 mm2/mmHg. The differences were significant for all three balloon fillings. No severe EndoFlip™ treatment-related adverse events occurred.
Conclusion
Measurement with EndoFlip™ is a safe and technically feasible endoscopic option for measuring the distensibility of the pylorus. Our study shows that the distensibility in asymptomatic patients after esophagectomy is significantly higher than that in patients suffering from DGCE. However, more studies need to be conducted to demonstrate the general use of EndoFlip™ measurement of the pylorus after esophagectomy.
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Mekaroonkamol P, Tiankanon K, Rerknimitr R. A New Paradigm Shift in Gastroparesis Management. Gut Liver 2022; 16:825-839. [PMID: 35670120 PMCID: PMC9668508 DOI: 10.5009/gnl210309] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 11/07/2021] [Accepted: 01/13/2022] [Indexed: 08/30/2023] Open
Abstract
Gastroparesis, once regarded as a rare disease, is difficult to diagnose and challenging to treat; there were many breakthrough advances in the 2010s, shifting the paradigm of the understanding of this complex entity and its management. Similar to diabetes, its increasing prevalence reflects increased accessibility to diagnostic modalities and suggests that gastroparesis was underacknowledged in the past. Major developments in the three main aspects of the disease include the discovery of smooth muscle cells, interstitial cells of Cajal, PDGFRα+ cells syncytium, rather than interstitial cells of Cajal alone, as the main gastric pacemaker unit; the development of validated point-of-care diagnostic modalities such as a wireless motility capsule, the carbon 13-labeled breath test, and impedance planimetry; and the introduction of novel minimally invasive therapeutic options such as newer pharmacologic agents and gastric peroral endoscopic pyloromyotomy. All aspects of these advances will be discussed further in this review.
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Affiliation(s)
- Parit Mekaroonkamol
- Division of Gastroenterology, Department of Medicine, King Chulalongkorn Memorial Hospital and Chulalongkorn University, Bangkok, Thailand
| | - Kasenee Tiankanon
- Division of Gastroenterology, Department of Medicine, King Chulalongkorn Memorial Hospital and Chulalongkorn University, Bangkok, Thailand
| | - Rungsun Rerknimitr
- Division of Gastroenterology, Department of Medicine, King Chulalongkorn Memorial Hospital and Chulalongkorn University, Bangkok, Thailand
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17
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Lorenz F, Brunner S, Berlth F, Dratsch T, Babic B, Fuchs HF, Schmidt T, Celik E, Dos Santos DP, Grimminger P, Bruns CJ, Goeser T, Chon SH. Using an Endoluminal Functional Lumen Imaging Probe (EndoFLIP™) to Compare Pyloric Function in Patients with Gastroparesis to Patients After Esophagectomy. J Gastrointest Surg 2022; 27:682-690. [PMID: 36376723 PMCID: PMC10073042 DOI: 10.1007/s11605-022-05502-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 10/22/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND Gastroparesis (GP) occurs in patients after upper gastrointestinal surgery, in patients with diabetes or systemic sclerosis and in idiopathic GP patients. As pyloric dysfunction is considered one of the underlying mechanisms, measuring this mechanism with EndoFLIP™ can lead to a better understanding of the disease. METHODS Between November 2021 and March 2022, we performed a retrospective single-centre study of all patients who had non-surgical GP, post-surgical GP and no sign of GP after esophagectomy and who underwent our post-surgery follow-up program with surveillance endoscopies and further exams. EndoFLIP™ was used to perform measurements of the pylorus, and distensibility was measured at 40 ml, 45 ml and 50 ml balloon filling. RESULTS We included 66 patients, and successful application of the EndoFLIP™ was achieved in all interventions (n = 66, 100%). We identified 18 patients suffering from non-surgical GP, 23 patients suffering from GP after surgery and 25 patients without GP after esophagectomy. At 40, 45 and 50 ml balloon filling, the mean distensibility in gastroparetic patients was 8.2, 6.2 and 4.5 mm2/mmHg; 5.4, 5.1 and 4.7 mm2/mmHg in post-surgical patients suffering of GP; and 8.5, 7.6 and 6.3 mm2/mmHg in asymptomatic post-surgical patients. Differences between symptomatic and asymptomatic patients were significant. CONCLUSION Measurement with EndoFLIP™ showed that asymptomatic post-surgery patients seem to have a higher pyloric distensibility. Pyloric distensibility and symptoms of GP seem to correspond.
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Affiliation(s)
- Florian Lorenz
- Department of Gastroenterology and Hepatology, Interdisciplinary Endoscopy Unit, University Hospital of Cologne, Cologne, Germany
| | - Stefanie Brunner
- Department of General, Visceral, Cancer and Transplant Surgery, University Hospital of Cologne, Kerpener Street 62, 50937, Cologne, Germany
| | - Felix Berlth
- Department of General, Visceral and Transplantation Surgery, University Hospital of Mainz, Mainz, Germany
| | - Thomas Dratsch
- Department of Diagnostic and Interventional Radiology, University Hospital of Cologne, Cologne, Germany
| | - Benjamin Babic
- Department of General, Visceral, Cancer and Transplant Surgery, University Hospital of Cologne, Kerpener Street 62, 50937, Cologne, Germany
| | - Hans Friedrich Fuchs
- Department of General, Visceral, Cancer and Transplant Surgery, University Hospital of Cologne, Kerpener Street 62, 50937, Cologne, Germany
| | - Thomas Schmidt
- Department of General, Visceral, Cancer and Transplant Surgery, University Hospital of Cologne, Kerpener Street 62, 50937, Cologne, Germany
| | - Erkan Celik
- Department of Diagnostic and Interventional Radiology, University Hospital of Cologne, Cologne, Germany
| | - Daniel Pinto Dos Santos
- Department of Diagnostic and Interventional Radiology, University Hospital of Cologne, Cologne, Germany
- Department of Radiology, University Hospital Frankfurt, Frankfurt, Germany
| | - Peter Grimminger
- Department of General, Visceral and Transplantation Surgery, University Hospital of Mainz, Mainz, Germany
| | - Christiane Josephine Bruns
- Department of General, Visceral, Cancer and Transplant Surgery, University Hospital of Cologne, Kerpener Street 62, 50937, Cologne, Germany
| | - Tobias Goeser
- Department of Gastroenterology and Hepatology, Interdisciplinary Endoscopy Unit, University Hospital of Cologne, Cologne, Germany
| | - Seung-Hun Chon
- Department of Gastroenterology and Hepatology, Interdisciplinary Endoscopy Unit, University Hospital of Cologne, Cologne, Germany.
- Department of General, Visceral, Cancer and Transplant Surgery, University Hospital of Cologne, Kerpener Street 62, 50937, Cologne, Germany.
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18
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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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19
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Abstract
Gastroparesis is characterized by symptoms suggesting retention of food in the stomach with objective evidence of delayed gastric emptying in the absence of mechanical obstruction in the gastric outflow. This condition is increasingly encountered in clinical practice. These guidelines summarize perspectives on the risk factors, diagnosis, and management of gastroparesis in adults (including dietary, pharmacological, device, and interventions directed at the pylorus), and they represent the official practice recommendations of the American College of Gastroenterology. The scientific evidence for these guidelines was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation process. When the evidence was not appropriate for Grading of Recommendations, Assessment, Development, and Evaluation, we used expert consensus to develop key concept statements. These guidelines should be considered as preferred but are not the only approaches to these conditions.
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20
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Santucci NR, Kemme S, El-Chammas KI, Chidambaram M, Mathur M, Castillo D, Sun Q, Fei L, Kaul A. Outcomes of combined pyloric botulinum toxin injection and balloon dilation in dyspepsia with and without delayed gastric emptying. Saudi J Gastroenterol 2022; 28:268-275. [PMID: 35083974 PMCID: PMC9408736 DOI: 10.4103/sjg.sjg_493_21] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Pyloric botulinum toxin injection has improved symptoms in children with delayed gastric emptying. We aimed to determine the clinical response to combined endoscopic intra-pyloric botulinum toxin injection and pyloric balloon dilation (IPBT-BD) in patients with dyspepsia. Methods Electronic medical records were reviewed to gather demographic data, symptoms, and follow-up on patients with dyspepsia. Cases were defined as those who underwent IPBT-BD in addition to their ongoing management. Controls received pharmacotherapy, behavioral intervention, or dietary management alone. Clinical response was defined as no change, partial, or complete improvement in symptoms within 12 months. Propensity score matching based on age, gender, and symptom duration was used to pair cases and controls. Results In total, 79 cases and 83 controls were identified. After propensity matching, 63 patients were included in each group. The mean age for cases was 14.5 ± 3.9y; 62% were females and 98% were Caucasian. Further, 83% of 46 cases and 94% of 49 controls who had scintigraphy scans showed delayed gastric emptying. After matching, 76% of cases showed partial or complete improvement compared with 49% controls within 12 months (P = 0.004). Younger children tended to respond more favorably to the procedure (P = 0.08). Conclusions In our propensity-matched analysis, combined IPBT-BD in addition to pharmacotherapy, behavioral, or dietary management clearly showed a benefit over these modalities alone. This favorable response lasted up to 12 months.
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Affiliation(s)
- Neha R Santucci
- Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, OH and Department of Pediatrics, University of Cincinnati College of Medicine, Denver, CO, United States of America
| | - Sarah Kemme
- Gastroenterology, Hepatology and Nutrition, Children's Hospital of Colorado, Denver, CO, United States of America
| | - Khalil I El-Chammas
- Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, OH and Department of Pediatrics, University of Cincinnati College of Medicine, Denver, CO, United States of America
| | - Maneesh Chidambaram
- Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, OH and Department of Pediatrics, University of Cincinnati College of Medicine, Denver, CO, United States of America
| | - Manav Mathur
- Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, OH and Department of Pediatrics, University of Cincinnati College of Medicine, Denver, CO, United States of America
| | - Daniel Castillo
- Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, OH and Department of Pediatrics, University of Cincinnati College of Medicine, Denver, CO, United States of America
| | - Qin Sun
- Biostatistics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States of America
| | - Lin Fei
- Biostatistics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States of America
| | - Ajay Kaul
- Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, OH and Department of Pediatrics, University of Cincinnati College of Medicine, Denver, CO, United States of America
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21
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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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22
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Endoscopic Management for Post-Surgical Complications after Resection of Esophageal Cancer. Cancers (Basel) 2022; 14:cancers14040980. [PMID: 35205730 PMCID: PMC8870330 DOI: 10.3390/cancers14040980] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 02/11/2022] [Accepted: 02/12/2022] [Indexed: 02/04/2023] Open
Abstract
Simple Summary Flexible endoscopy has an important part in the diagnosis and treatment of postoperative complications after oncologically intended esophagectomy. Endoscopy offers the possibility of effective therapy with minimal invasiveness at the same time, and the use of endoscopic therapy procedures can avoid re-operations. In this review we present the advantages of endoscopic treatment opportunities during the last 20 years regarding patients’ treatment after esophageal cancer resection. According to prevalence and clinical relevance, four relevant postoperative complications were identified and their endoscopic treatment procedures discussed. All endoscopic therapy procedures for anastomotic bleeding, anastomotic insufficiencies, anastomotic stenosis and postoperative delayed gastric emptying are presented, including innovative developments. Abstract Background: Esophageal cancer (EC) is the sixth-leading cause of cancer-related deaths in the world. Esophagectomy is the most effective treatment for patients without invasion of adjacent organs or distant metastasis. Complications and relevant problems may occur in the early post-operative course or in a delayed fashion. Here, innovative endoscopic techniques for the treatment of postsurgical problems were developed during the past 20 years. Methods: Endoscopic treatment strategies for the following postoperative complications are presented: anastomotic bleeding, anastomotic insufficiency, delayed gastric passage and anastomotic stenosis. Based on a literature review covering the last two decades, therapeutic procedures are presented and analyzed. Results: Addressing the four complications mentioned, clipping, stenting, injection therapy, dilatation, and negative pressure therapy are successfully utilized as endoscopic treatment techniques today. Conclusion: Endoscopic treatment plays a major role in both early-postoperative and long-term aftercare. During the past 20 years, essential therapeutic measures have been established. A continuous development of these techniques in the field of endoscopy can be expected.
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Verga MC, Mazza S, Azzolini F, Cereatti F, Conti CB, Drago A, Soro S, Elvo B, Grassia R. Gastric per-oral endoscopic myotomy: Indications, technique, results and comparison with surgical approach. World J Gastrointest Surg 2022; 14:12-23. [PMID: 35126859 PMCID: PMC8790331 DOI: 10.4240/wjgs.v14.i1.12] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 07/20/2021] [Accepted: 12/23/2021] [Indexed: 02/06/2023] Open
Abstract
Gastroparesis is a chronic disease of the stomach that causes a delayed gastric emptying, without the presence of a stenosis. For 30 years the authors identified pylorospasm as one of the most important pathophysiological mechanisms determining gastroparesis. Studies with EndoFLIP, a device that assesses pyloric distensibility, increased the knowledge about pylorospasm. Based on this data, several pyloric-targeted therapies were developed to treat refractory gastroparesis: Surgical pyloroplasty and endoscopic approach, such as pyloric injection of botulinum and pyloric stenting. Notwithstanding, the success of most of these techniques is still not complete. In 2013, the first human gastric per-oral endoscopic myotomy (GPOEM) was performed. It was inspired by the POEM technique, with a similar dissection method, that allows pyloromyotomy. Therapeutical results of GPOEM are similar to surgical approach in term of clinical success, adverse events and post-surgical pain. In the last 8 years GPOEM has gained the attention of the scientific community, as a minimally invasive technique with high rate of clinical success, quickly prevailing as a promising therapy for gastroparesis. Not surprisingly, in referral centers, its technical success rate is 100%. One of the main goals of recent studies is to identify those patients that will respond better to the therapies targeted on pylorus and to choose the better approach for each patient.
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Affiliation(s)
- Maria Chiara Verga
- Gastroenterology and Digestive Endoscopy Unit, ASST Cremona, Cremona 26100, Italy
| | - Stefano Mazza
- Gastroenterology and Digestive Endoscopy Unit, ASST Cremona, Cremona 26100, Italy
| | - Francesco Azzolini
- Gastroenterology and Digestive Endoscopy Unit, Ospedale San Raffaele IRCCS, Milano 20132, Italy
| | - Fabrizio Cereatti
- Gastroenterology and Digestive Endoscopy Unit, ASST Cremona, Cremona 26100, Italy
| | | | - Andrea Drago
- Gastroenterology and Digestive Endoscopy Unit, ASST Cremona, Cremona 26100, Italy
| | - Sara Soro
- Gastroenterology and Digestive Endoscopy Unit, ASST Cremona, Cremona 26100, Italy
| | - Biagio Elvo
- Gastroenterology and Digestive Endoscopy Unit, ASST Cremona, Cremona 26100, Italy
| | - Roberto Grassia
- Gastroenterology and Digestive Endoscopy Unit, ASST Cremona, Cremona 26100, Italy
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Ferhatoglu MF, Kartal A, Filiz AI, Kebudi A. Outcome of Gastric Fundus and Pylorus Botulinum Toxin A Injection in Obese Patients Class I–II with Normal Pyloric Orifice Structure: A Retrospective Analysis. Bariatr Surg Pract Patient Care 2021. [DOI: 10.1089/bari.2020.0112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Murat Ferhat Ferhatoglu
- Department of General Surgery, Faculty of Medicine, Istanbul Okan University, Istanbul, Turkey
| | | | - Ali Ilker Filiz
- Department of General Surgery, Baskent University Faculty of Medicine, Ankara, Turkey
| | - Abut Kebudi
- Department of General Surgery, Faculty of Medicine, Istanbul Okan University, Istanbul, Turkey
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25
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Murray FR, Schindler V, Hente JM, Fischbach LM, Schnurre L, Deibel A, Hildenbrand FF, Tatu AM, Pohl D. Pyloric dilation with the esophageal functional lumen imaging probe in gastroparesis improves gastric emptying, pyloric distensibility, and symptoms. Gastrointest Endosc 2021; 94:486-494. [PMID: 33771556 DOI: 10.1016/j.gie.2021.03.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 03/14/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS The role of decreased pyloric distensibility in gastroparesis as measured by the endolumenal functional luminal imaging probe (EndoFLIP) has been receiving increasing attention. In this study, we present clinical outcomes to pyloric dilation with the esophageal FLIP (EsoFLIP) in regard to gastric emptying, symptom evolution, and FLIP metrics. METHODS Patients evaluated for gastroparesis (gastric emptying studies of t1/2 ≥180 minutes during 13C-octanoic acid breath test and/or gastric remnants during gastroscopy after a sufficient fasting period) were scheduled for EsoFLIP controlled pyloric dilation. Pre- and postprocedural gastric emptying studies, questionnaires (Patient Assessment of Upper GI Symptoms Severity Index [PAGI-SYM; including the Gastroparesis Cardinal Symptom Index] and Patient Assessment of Quality of Life Index [PAGI-QOL]), and FLIP metrics were documented. Dilation was conducted according to a self-developed algorithm. RESULTS Forty-six patients were analyzed (72% women; median age, 39 years [range, 18-88]). Etiologies of gastroparesis were diabetic in 10 patients (22%), idiopathic in 33 (72%), and postoperative in 3 (6%). Postprocedural gastric emptying time decreased from a median of 211 minutes to 179 minutes (P = .001). In accordance, pyloric distensibility, PAGI-SYM, PAGI-QOL, and Gastroparesis Cardinal Symptom Index values improved significantly. After a median follow-up of 3.9 months, 57% of all treated patients with returned questionnaires reported improved symptoms. CONCLUSIONS Pyloric EsoFLIP controlled dilation shows value in the treatment of gastroparesis, both subjectively and objectively. Long-term follow-up to assess efficacy and comparative trials are warranted.
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Affiliation(s)
- Fritz Ruprecht Murray
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Valeria Schindler
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Juliane Marie Hente
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Lara Maria Fischbach
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Larissa Schnurre
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Ansgar Deibel
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | | | - Aurora Maria Tatu
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
| | - Daniel Pohl
- Department of Gastroenterology and Hepatology, University Hospital Zurich, Zurich, Switzerland
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Abstract
Until recently, gastric motility measurements in humans were mostly limited to accommodation (using barostat or 3-dimensional imaging studies of gastric volume) and gastric emptying tests, the latter being the only one performed in routine clinical care. Accurate and easy to use techniques were lacking to assess pyloric function in health and disease. Recently, pyloric distensibility has been developed and validated to assess pyloric opening. Several studies confirmed that pyloric distensibility was decreased in gastroparesis and correlated with gastric emptying as well as gastroparesis symptoms. In addition, pyloric distensibility may predict outcome of endoscopic techniques targeting the pylorus, namely intrapyloric botulinum toxin injection and gastric per-oral pyloromyotomy. Pyloric distensibility appears therefore to be a promising and useful new tool in the workup of gastroparesis patients.
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Affiliation(s)
- Fabien Wuestenberghs
- Department of Physiology, Institut National de la Santé et de la Recherche Médicale Unit 1073 and Clinical Investigation Centre-Centre de Ressource Biologiqu 1404, Rouen University Hospital, UNIROUEN, Normandie University, Rouen, France.,Department of Gastroenterology and Hepatology, Centre Hospitalier Universitaire UCLouvain Namur, Godinne University Hospital, UCLouvain, Yvoir, Belgium
| | - Guillaume Gourcerol
- Department of Physiology, Institut National de la Santé et de la Recherche Médicale Unit 1073 and Clinical Investigation Centre-Centre de Ressource Biologiqu 1404, Rouen University Hospital, UNIROUEN, Normandie University, Rouen, France
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Desprez C, Chambaz M, Melchior C, Basile P, Prevost G, Jacques J, Leroi AM, Gourcerol G. Assessment of pyloric sphincter distensibility and pressure in patients with diabetic gastroparesis. Neurogastroenterol Motil 2021; 33:e14064. [PMID: 33314491 DOI: 10.1111/nmo.14064] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 10/16/2020] [Accepted: 11/25/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Recent studies have shown that pyloric distensibility is altered in 30-50% of gastroparetic patients but the number of diabetic patients included in prior reports has been small. The aim of the present study was to assess pyloric sphincter measurements in diabetic patients with gastroparesis and to determine whether diabetes characteristics were correlated to pyloric disfunction. METHODS Pyloric distensibility and pressure were measured using EndoFLIP® system in 46 patients with diabetic gastroparesis (DGP) and compared with 21 healthy volunteers (HV), and 33 patients with idiopathic gastroparesis (IGP). Altered pyloric distensibility was defined as the measurement below 10 mm2 /mmHg at 40 ml of inflation. In diabetic patients, blood glucose, glycated hemoglobin, duration, complications, and treatments were collected. KEY RESULTS Mean pyloric distensibility at 40 ml of inflation was lower in DGP and IGP groups with, respectively, 10.8 ± 0.9 mm2 /mmHg and 14.8 ± 2.2 mm2 /mmHg in comparison with the HV group (25.2 ± 2.3 mm2 /mmHg; p < 0.005). 56.5% of patients had a decreased pyloric distensibility in the DGP group, 51.5% of patients in the IGP group, and 10% of patients in the HV group. No correlation was found between pyloric sphincter measurements and diabetes characteristics, including blood glucose, glycated hemoglobin, diabetes mellitus type, neuropathy, or GLP1 agonists intake. CONCLUSION AND INTERFERENCES Pyloric sphincter distensibility and pressure were altered both in diabetic and idiopathic gastroparesis. Pyloric sphincter distensibility was not correlated to diabetes parameters.
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Affiliation(s)
- Charlotte Desprez
- Digestive Physiology Department, Rouen University Hospital, Rouen, France.,Nutrition, Brain and Gut Laboratory UMR 1073, Rouen University, Rouen, France
| | - Marion Chambaz
- Gastroenterology Department, Rennes University Hospital, Rennes, France
| | - Chloé Melchior
- Nutrition, Brain and Gut Laboratory UMR 1073, Rouen University, Rouen, France.,Gastroenterology Department, Rouen University Hospital, Rouen, France
| | - Paul Basile
- Gastroenterology Department, Rouen University Hospital, Rouen, France
| | - Gaetan Prevost
- Endocrinology Department, Rouen University Hospital, Rouen, France
| | - Jérémie Jacques
- Gastroenterology Department, Limoges University Hospital, Limoges, France
| | - Anne-Marie Leroi
- Digestive Physiology Department, Rouen University Hospital, Rouen, France.,Nutrition, Brain and Gut Laboratory UMR 1073, Rouen University, Rouen, France.,INSERM CIC-CRB 1404, Rouen University Hospital, Rouen, France
| | - Guillaume Gourcerol
- Digestive Physiology Department, Rouen University Hospital, Rouen, France.,Nutrition, Brain and Gut Laboratory UMR 1073, Rouen University, Rouen, France.,INSERM CIC-CRB 1404, Rouen University Hospital, Rouen, France
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Shanker A, Bashashati M. Measurement of Pyloric Pressures in Gastroparesis: Stiff Competition from EndoFLIP™. Dig Dis Sci 2021; 66:2475-2477. [PMID: 32945984 DOI: 10.1007/s10620-020-06603-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/03/2020] [Indexed: 12/09/2022]
Affiliation(s)
- Aaron Shanker
- Department of Internal Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
| | - Mohammad Bashashati
- Center for Neurogastroenterology and GI Motility, Division of Gastroenterology, Department of Medicine, Texas Tech University Health Sciences Center El Paso, 4800 Alberta Ave, El Paso, TX, 79905, USA.
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Tan J, Shrestha SM, Wei M, Wang P, Shi J, Lu Y, Gao Q, Lu T, Zhou J, Shi R. Feasibility, safety, and long-term efficacy of gastric peroral endoscopic myotomy (G-POEM) for postsurgical gastroparesis: a single-center and retrospective study of a prospective database. Surg Endosc 2021; 35:3459-3470. [PMID: 32880749 PMCID: PMC8195960 DOI: 10.1007/s00464-020-07793-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Accepted: 07/07/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Postsurgical gastroparesis is recognized as a gastrointestinal dysfunction syndrome following foregut surgery. Gastric peroral endoscopic myotomy (G-POEM) is suggested as a minimally invasive therapy for gastroparesis. But the long-term efficacy and safety of G-POEM in treating postsurgical gastroparesis are rarely explored. METHODS The primary outcomes included the symptomatic improvement based on gastroparesis cardinal symptoms index (GCSI) and the improvement of gastric emptying. The secondary outcomes included the improvement of gastroesophageal reflux symptoms and complications of G-POEM. RESULTS The severity of postsurgical gastroparesis was not associated with the onset time and the course of the disease. G-POEM significantly reduced GCSI throughout the follow-up period (p < 0.0001). For different anastomotic site, a significant improvement of GCSI was found at 6 month post-G-POEM (F4,165 = 74.18, p < 0.0001). Subscale analysis of GCSI showed that nausea/vomiting, post-prandial fullness/early satiety, and bloating were improved significantly at 6-month post-G-POEM (p < 0.0001, respectively). Half-emptying and whole-emptying time were significantly shortened in patients with different anastomotic site post-G-POEM (half-emptying time: F3,174 = 65.44, p < 0.0001; whole-emptying time: F3,174 = 54.85, p < 0.0001). The emptying of ioversol was obviously accelerated after G-POEM. GCSI wasn't related to pyloric length, pyloric diameter, and thickness of pyloric wall. GERDQ was also used to evaluate the clinical efficacy of G-POEM. For each time points, GERDQ didn't differ significantly in patients with different anastomotic site (F4,104 = 0.8075, p = 0.5231). For patients with different anastomotic site, GERDQ was improved significantly at different time points (F4,104 = 59.11, p < 0.0001). The higher the esophageal anastomotic site was, the faster G-POEM improved the symptoms of gastroesophageal reflux. No one required re-hospitalization for any complication. CONCLUSION G-POEM is a minimally invasive therapy with long-term effectiveness and safety in treating postsurgical gastroparesis.
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Affiliation(s)
- Jiacheng Tan
- Department of Gastroenterology, Zhongda Hospital Southeast University, No. 87 Dingjiaqiao, Nanjing, 210009, Jiangsu, China
| | - Sachin Mulmi Shrestha
- Department of Gastroenterology, Zhongda Hospital Southeast University, No. 87 Dingjiaqiao, Nanjing, 210009, Jiangsu, China
| | - Ming Wei
- Department of Gastroenterology, Zhongda Hospital Southeast University, No. 87 Dingjiaqiao, Nanjing, 210009, Jiangsu, China
| | - Panpan Wang
- Department of Gastroenterology, Zhongda Hospital Southeast University, No. 87 Dingjiaqiao, Nanjing, 210009, Jiangsu, China
| | - Jinjun Shi
- Department of Ultrasound, Zhongda Hospital Southeast University, Nanjing, 210009, Jiangsu, China
| | - Yanjia Lu
- Department of Ultrasound, Zhongda Hospital Southeast University, Nanjing, 210009, Jiangsu, China
| | - Qi Gao
- Department of Ultrasound, Zhongda Hospital Southeast University, Nanjing, 210009, Jiangsu, China
| | - Tong Lu
- Department of Radiology, Zhongda Hospital Southeast University, Nanjing, 210009, Jiangsu, China
| | - Jun Zhou
- Medical Division, Yidu Cloud (Beijing) Technology Co., Ltd, Beijing, 100191, China
| | - Ruihua Shi
- Department of Gastroenterology, Zhongda Hospital Southeast University, No. 87 Dingjiaqiao, Nanjing, 210009, Jiangsu, China.
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30
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The Utility of EndoFLIP for Measuring Gastrojejunal Anastomosis Diameter and Distensibility in Patients Experiencing Weight Regain Post Roux-en-Y Gastric Bypass. Obes Surg 2021; 31:3353-3359. [PMID: 33646518 DOI: 10.1007/s11695-021-05302-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 02/12/2021] [Accepted: 02/12/2021] [Indexed: 10/22/2022]
Abstract
A dilated gastrojejunal anastomosis (GJA) diameter is an independent predictor of weight regain following Roux-en-Y gastric bypass (RYGB). Despite this, there is no standardized method for GJA diameter measurement. We performed a retrospective analysis to compare endoscopic visual estimation and endoluminal functional impedance planimetry (EndoFLIP) for measuring GJA diameter in patients with weight regain post-RYGB. Visual estimation was found to overestimate GJA diameter by a mean of 4.2mm ± 4.6mm when compared with EndoFLIP. Furthermore, we identified symptomatic patients with normal GJA diameter but increased distensibility, which may represent a previously unrecognized subgroup. Our findings suggest the potential utility of EndoFLIP in the evaluation of post-RYGB weight regain and support the need for prospective studies to investigate the relationship between GJA distensibility and weight regain.
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31
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Conchillo JM, Straathof JWA, Mujagic Z, Brouns JH, Bouvy ND, Keszthelyi D, Masclee AA. Gastric peroral endoscopic pyloromyotomy for decompensated gastroparesis: comprehensive motility analysis in relation to treatment outcomes. Endosc Int Open 2021; 9:E137-E144. [PMID: 33532550 PMCID: PMC7834704 DOI: 10.1055/a-1311-0859] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 10/05/2020] [Indexed: 12/26/2022] Open
Abstract
Background and study aims There are no reliable data to predict which patients with gastroparesis (GP) would benefit the most from gastric peroral endoscopic pyloromyotomy (G-POEM). The aim of the present study was to assess whether antro-duodenal motility patterns and pyloric distensibility can predict the outcome of G-POEM in patients with decompensated GP. Patients and methods In an open-label study, patients with GP and refractory symptoms were eligible for treatment with G-POEM if treatment attempts according to a standardized stepwise protocol had failed. Baseline assessment included Gastroparesis Cardinal Symptom Index (GCSI), C13-octanoic gastric emptying breath test and high-resolution antro-duodenal manometry. Pyloric distensibility using EndoFlip measurements was assessed at baseline and 3 months after the procedure. Explorative analyses were performed on potential predictors of response using logistic regression analyses. Results Twenty-four patients with decompensated GP underwent G-POEM. At baseline, 78.3 % and 61.9 % of patients showed antral hypomotility and neuropathic motor patterns, respectively. The technical success rate was 100 % (24/24). Mean GCSI improved significantly at 3, 6, and 12 months after G-POEM ( P = 0.01). Median distensibility index (DI) improved significantly as compared with baseline (7.5 [6.9;11.7] vs. 5.3[3.1;8.1], P = 0.004). A significant correlation was found between clinical response at 6 months and pyloric DI improvement ( P = 0.003). No potential predictors of clinical response after G-POEM could be identified in an explorative analysis. Conclusions G-POEM improved pyloric distensibility patterns in patients with decompensated GP. Clinical response at 6 months after G-POEM was associated with pyloric distensibility improvement. However, no potential predictors of response could be identified from either antro-duodenal motility patterns or pyloric distensibility.
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Affiliation(s)
- José M. Conchillo
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Jan Willem A. Straathof
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Zlatan Mujagic
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Jenny H. Brouns
- Department of Dietetics, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Nicole D. Bouvy
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Daniel Keszthelyi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Ad A.M. Masclee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
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32
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Fathalizadeh A, Klingler M, Landreneau J, Allemang M, Rodriguez J, Ponsky J, El-Hayek K. Real-time intraoperative functioning lumen imaging probe during endoscopic per-oral pyloromyotomy (pop). Surg Endosc 2021; 36:745-752. [PMID: 33427911 PMCID: PMC8741673 DOI: 10.1007/s00464-020-08237-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Accepted: 12/08/2020] [Indexed: 01/12/2023]
Abstract
Background Endoscopic per-oral pyloromyotomy (POP) has emerged as a safe and effective first line option in medically refractory gastroparesis. Determining the appropriate extent of the pyloromyotomy continues to present a challenge as there are no standardized tools for measuring changes in pyloric distensibility during the procedure. The objective of this study was to evaluate the utility of using impedance planimetry with endoscopic functional luminal imaging probe (FLIP) to measure changes in pyloric distensibility after POP, and to compare these changes with improvement in symptoms and objective gastric emptying. Methods Patients with medically refractory gastroparesis underwent POP with FLIP measurements of the pylorus (EndoFLIP®, Medtronic, Fridley MN). FLIP measurements, as well as changes in symptoms measured by the validated gastroparesis cardinal symptom index (GCSI) and scintigraphic gastric emptying studies (GES), were evaluated before and after POP. Results A total of 14 patients underwent measurement with FLIP during POP, 12 of whom had pre- and post-POP measurements. Mean pyloric diameter increased by 1.4 mm, from 13.9 mm to 15.3 mm (p = 0.0012). Mean distensibility index increased from 6.2 mm2/mmHg to 9.1 mm2/mmHg (p = 0.0074). Successful division of the pylorus was achieved in 100% of patients with a mean operative time of 36 min and no perioperative complications. The mean length of stay was 0.7 days (0–3 days). Post-POP mean GCSI score improved from 2.97 to 2.28 at a mean follow-up time of 27 days (p < 0.001). Objective improvement in gastric emptying was observed in 80% of patients with scintigraphic GES, with mean four-hour retention decreasing from 46.3% to 32.4% (p < 0.007). Conclusions FLIP is a safe and feasible tool to provide objective measurements during POP. Larger cohorts with longer follow-up are required to determine if measured improvements in pyloric diameter and distensibility are predictive of sustained improvements in GCSI and GES.
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Affiliation(s)
- Alisan Fathalizadeh
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Michael Klingler
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Joshua Landreneau
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Matthew Allemang
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - John Rodriguez
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.,Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Jeffrey Ponsky
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.,Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Kevin El-Hayek
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.,Division of General Surgery, MetroHealth System, Cleveland, OH, USA.,Case Western Reserve University School of Medicine, Cleveland, OH, USA
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Limketkai BN, LeBrett W, Lin L, Shah ND. Nutritional approaches for gastroparesis. Lancet Gastroenterol Hepatol 2020; 5:1017-1026. [PMID: 33065041 DOI: 10.1016/s2468-1253(20)30078-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 03/05/2020] [Accepted: 03/06/2020] [Indexed: 12/12/2022]
Abstract
Patients with gastroparesis often have signs and symptoms including nausea, vomiting, epigastric discomfort, and early satiety, thus leading to inadequate food intake and a high risk of malnutrition. There is a considerable scarcity of data about nutritional strategies for gastroparesis, and current practices rely on extrapolated evidence. Some approaches include the modification of food composition, food consistency, and food volume in the context of delayed gastric emptying. If the patient is unable to consume adequate calories through a solid food diet, stepwise nutritional interventions could include the use of liquid meals, oral nutrition supplements, enteral nutrition, and parenteral nutrition. This Review discusses the role, rationale, and current evidence of diverse nutritional interventions in the management of gastroparesis.
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Affiliation(s)
- Berkeley N Limketkai
- Vatche and Tamar Manoukian Division of Digestive Diseases, UCLA School of Medicine, Los Angeles, CA, USA.
| | - Wendi LeBrett
- Vatche and Tamar Manoukian Division of Digestive Diseases, UCLA School of Medicine, Los Angeles, CA, USA
| | - Lisa Lin
- Vatche and Tamar Manoukian Division of Digestive Diseases, UCLA School of Medicine, Los Angeles, CA, USA
| | - Neha D Shah
- Nutrition and Food Services, University of California San Francisco, San Francisco, CA, USA
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Watts LS, Baker JR, Lee AA, Harer K, Bowers N, Law R, Hasler WL. Impact of gastric per-oral endoscopic myotomy on static and dynamic pyloric function in gastroparesis patients. Neurogastroenterol Motil 2020; 32:e13892. [PMID: 32542920 DOI: 10.1111/nmo.13892] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 04/23/2020] [Accepted: 04/30/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Functional Lumen Imaging Probe (EndoFLIP) tests typically measure static pyloric parameters, but the pylorus exhibits phasic variations on manometry. Dynamic changes in pyloric function have not been quantified using EndoFLIP, and the impact of Gastric Per-Oral Endoscopic Myotomy (G-POEM) on static and dynamic pyloric activity in gastroparesis is unknown. METHODS EndoFLIP balloon inflation to 30, 40, and 50 mL was performed to measure mean, maximum, and minimum values and variability in pyloric diameter and distensibility before and after G-POEM in 20 patients with refractory gastroparesis. The impact of phasic contractions on these pyloric measures was compared. KEY RESULTS G-POEM increased mean (P < .0001) and maximum (P = .0002) pyloric diameters and mean (P = .02) and maximum (P = .02) pyloric distensibility on 50 mL EndoFLIP inflation but not intraballoon pressures or minimum diameters or distensibility. Temporal variability of pyloric diameter (P = .02) and distensibility (P = .02) also increased after G-POEM. Phasic coupled contractions propagating from the antrum through the pylorus were observed in 37.5% of recordings; other phasic activity including isolated pyloric contractions were seen in 23.3%. Variability of pyloric diameter and distensibility tended to be higher during recordings with phasic activity. Some pyloric responses to G-POEM were influenced by age, gastroparesis etiology, gastric emptying, and prior botulinum toxin injection. CONCLUSIONS & INFERENCES Pyloric activity exhibits dynamic changes on EndoFLIP testing in gastroparesis. G-POEM increases maximal but not minimal diameter and distensibility with increased variations, suggesting this therapy enhances pyloric opening but may not impair pyloric closure. Phasic pyloric contractions contribute to variations in pyloric activity.
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Affiliation(s)
- Lydia S Watts
- Division of Gastroenterology and Hepatology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Jason R Baker
- Division of Gastroenterology and Hepatology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Allen A Lee
- Division of Gastroenterology and Hepatology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Kimberly Harer
- Division of Gastroenterology and Hepatology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Nicole Bowers
- Division of Gastroenterology and Hepatology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Ryan Law
- Division of Gastroenterology and Hepatology, University of Michigan Health System, Ann Arbor, MI, USA
| | - William L Hasler
- Division of Gastroenterology and Hepatology, University of Michigan Health System, Ann Arbor, MI, USA
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35
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Per Oral Pyloromyotomy for Gastroparesis: A Systematic Review of the Current Literature and Future Recommendations. GASTROINTESTINAL DISORDERS 2020. [DOI: 10.3390/gidisord2040038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background: Gastric per oral endoscopic myotomy (GPOEM) was developed as a therapeutic option for gastroparesis after the pylorus was identified as a key target for gastroparesis management. This study includes a systematic literature review of studies in which GPOEM was utilized as therapy for gastroparesis. Methods: A literature search was conducted in three databases (MEDLINE, Scopus and Embase) of articles that included the keywords “GPOEM”, “Gastric per oral endoscopy myotomy” or “per oral pyloromyotomy” and “Gastroparesis” in the abstract or title. The search covered articles published until 29 February 2020. Results: A total of 139 articles were identified. Only 15 articles met the final inclusion criteria and were retrieved for qualitative data synthesis. Conclusion: GPOEM for gastroparesis is shown to have a high success rate among the studies but data interpretations are limited because of small sample sizes and short follow-up. Subjective and objective data prior to and post-GPOEM will be mandatory to establish credibility. The procedure is technically feasible and safe based on the limited studies available.
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Desprez C, Roman S, Leroi AM, Gourcerol G. The use of impedance planimetry (Endoscopic Functional Lumen Imaging Probe, EndoFLIP ® ) in the gastrointestinal tract: A systematic review. Neurogastroenterol Motil 2020; 32:e13980. [PMID: 32856765 DOI: 10.1111/nmo.13980] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 08/03/2020] [Accepted: 08/05/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND PURPOSE The EndoFLIP® system is a method of delineating impedance and was first designed to investigate the characteristics of the esophago-gastric junction. In the last decade, its use was widened to investigate other sphincteric and non-sphincteric systems of the gastrointestinal tract. The objective of the present systematic review was to summarize the available data in literature on the use of the EndoFLIP® system in the gastrointestinal tract, including sphincteric and non-sphincteric regions. We performed a systematic review in accordance with recommendations for systematic review using PRISMA guidelines without date restriction, until June 2020, using MEDLINE-PubMed, Cochrane Library, and Google Scholar databases. Only articles written in English were included in the present review. Five hundred and six unique citations were identified from all database combined. Of those, 95 met the inclusion criteria. There was a lack of standardization among studies in terms of anesthetic drugs use, probe placement, and inflation protocol. In most cases, only small cohorts of patients were included. Most studies investigated the EGJ, with a potential use of the EndoFLIP® to identify a subgroup of patients with achalasia and for intraoperative assessment of treatment efficacy in achalasia. However, the use of EndoFLIP® in the esophageal body (esophageal panometry), other esophageal diseases (gastro-esophageal reflux disease, eosinophilic esophagitis), and other sphincter regions (anal canal, pylorus) will need further confirmatory studies. The EndoFLIP® system provides detailed geometric data of the gastrointestinal lumen but further works are needed to determine its use in clinical practice.
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Affiliation(s)
- Charlotte Desprez
- Digestive Physiology Department, Rouen University Hospital, Rouen, France
- Nutrition, Brain and Gut Laboratory, INSERM unit 1073, Rouen University Hospital, Rouen, France
| | - Sabine Roman
- Digestive Physiology Department, Hospices Civils de Lyon, Hopital H Herriot, Lyon, France
| | - Anne Marie Leroi
- Digestive Physiology Department, Rouen University Hospital, Rouen, France
- Nutrition, Brain and Gut Laboratory, INSERM unit 1073, Rouen University Hospital, Rouen, France
- Clinical Investigation Center, CIC-CRB 1404, Rouen University Hospital, Rouen, France
| | - Guillaume Gourcerol
- Digestive Physiology Department, Rouen University Hospital, Rouen, France
- Nutrition, Brain and Gut Laboratory, INSERM unit 1073, Rouen University Hospital, Rouen, France
- Clinical Investigation Center, CIC-CRB 1404, Rouen University Hospital, Rouen, France
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Dorsey YC, Posner S, Patel A. Esophageal Functional Lumen Imaging Probe (FLIP): How Can FLIP Enhance Your Clinical Practice? Dig Dis Sci 2020; 65:2473-2482. [PMID: 32671586 DOI: 10.1007/s10620-020-06443-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 06/21/2020] [Indexed: 12/11/2022]
Abstract
Recent innovations in esophageal diagnostic testing have enhanced gastroenterology clinical practice by facilitating more nuanced and advanced evaluation of esophageal symptoms. Among these pivotal advances is the FDA-approved functional lumen imaging probe (FLIP), which utilizes impedance planimetry via volumetric distension of a catheter-mounted balloon at the time of sedated upper endoscopy, to acquire esophageal dimensions and pressures. In real time, FLIP can display cross-sectional areas (CSA) and distensibility indices (ratios of CSA to intra-balloon pressures) throughout the esophagus, most notably at the esophagogastric junction, as well as secondary peristaltic esophageal body contractile patterns. As the use of FLIP has progressively spread and permeated into the practice of clinical gastroenterology since its introduction, increasing data on and experiences with its applications have accumulated to guide its utility in clinical practice. In this current review developed for gastroenterologists and foregut surgeons across clinical practice, we provide an introduction to FLIP technology and metrics and discuss the clinical scenarios in which performance of or referral for FLIP may be helpful in the evaluation and management of patients with commonly encountered esophageal symptoms and disorders. Specifically, we discuss the potential applications and limitations of FLIP as a complementary diagnostic modality in patients with non-obstructive dysphagia, established or suspected achalasia spectrum disorders, eosinophilic esophagitis, gastroesophageal reflux disease and those undergoing esophageal surgery.
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Affiliation(s)
- Y Claire Dorsey
- Division of Gastroenterology, Duke University School of Medicine, DUMC Box 3913, Durham, NC, 27710, USA.,Division of Gastroenterology, Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - Shai Posner
- Division of Gastroenterology, Duke University School of Medicine, DUMC Box 3913, Durham, NC, 27710, USA.,Division of Gastroenterology, Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - Amit Patel
- Division of Gastroenterology, Duke University School of Medicine, DUMC Box 3913, Durham, NC, 27710, USA. .,Division of Gastroenterology, Durham Veterans Affairs Medical Center, Durham, NC, USA.
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Clarke JO, Ahuja NK, Fernandez-Becker NQ, Gregersen H, Kamal AN, Khan A, Lynch KL, Vela MF. The functional lumen imaging probe in gastrointestinal disorders: the past, present, and future. Ann N Y Acad Sci 2020; 1482:16-25. [PMID: 32814368 DOI: 10.1111/nyas.14463] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 07/08/2020] [Accepted: 07/22/2020] [Indexed: 12/14/2022]
Abstract
The functional lumen imaging probe (FLIP) is a diagnostic tool that utilizes impedance planimetry to allow the assessment of luminal diameter and distensibility. It has been used primarily in esophageal diseases, in particular, in the assessment of achalasia, esophagogastric junction outflow obstruction, and eosinophilic esophagitis (EoE). The usage and publications have increased over the past decade and it is now an essential tool in the armamentarium of the esophagologist. Indications are emerging outside of the esophagus, in particular with regard to gastroparesis. Our paper will review the history of FLIP, optimal current usage, data for key esophageal disorders (including achalasia, reflux, and EoE), data for nonesophageal disorders, and our sense as to whether FLIP is ready for prime time, as well as gaps in evidence and suggestions for future research.
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Affiliation(s)
- John O Clarke
- Department of Medicine, Stanford University, Redwood City, California
| | - Nitin K Ahuja
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Hans Gregersen
- Department of Surgery, the Chinese University of Hong Kong, Hong Kong, China
| | - Afrin N Kamal
- Department of Medicine, Stanford University, Redwood City, California
| | - Abraham Khan
- Department of Medicine, New York University, New York, New York
| | - Kristie L Lynch
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Marcelo F Vela
- Gastroenterology Division, The Mayo Clinic, Scottsdale, Arizona
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Wellington J, Stuart P, Westcott C, Koch KL. Obstructive Gastroparesis: Patient Selection and Effect of Laparoscopic Pyloroplasty. J Gastrointest Surg 2020; 24:1778-1784. [PMID: 31270719 DOI: 10.1007/s11605-019-04240-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 04/21/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Functional obstructive gastroparesis is an understudied subtype of gastroparesis with normal 3 cycle per minute gastric myoelectrical activity that responds to botulinum toxin A injection and balloon dilation of the pylorus. AIMS To determine the effect of pyloroplasty on symptoms, weight, gastric emptying, and gastric myoelectrical activity in patients with gastroparesis and normal 3 cycle per minute gastric myoelectrical activity. METHODS Ten patients (average age 36 years with gastroparesis and normal 3 cycle per minute gastric myoelectrical activity) who had at least two successful endoscopic pyloric therapies and then underwent pyloroplasty were identified. Electrogastrography with water load satiety test was performed to determine gastric myoelectrical activity. Gastric emptying was measured with 4-h scintigraphy. KEY RESULTS Six months after pyloroplasty, nine of ten patients reported improved symptoms and weight increased an average of 6.4 lb (p = 0.04). The average percentage of meal retained at 4 h decreased from 47% before to 16% after pyloroplasty (p < 0.01) and normalized in six patients. After pyloroplasty, the percent distribution of gastric myoelectrical activity power in the 3 cycle per minute range decreased at each measured interval compared with pre-pyloroplasty (p < 0.01). CONCLUSIONS (1) Pyloroplasty in these patients with obstructive gastroparesis improved gastric emptying and decreased 3 cycle per minute gastric myoelectrical activity, consistent with relief of functional gastric outlet obstruction. (2) Pyloric neuromuscular dysfunction is a key factor in delayed emptying in patients with functional obstructive gastroparesis.
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Affiliation(s)
- Jennifer Wellington
- Section on Gastroenterology, Department of Surgical Services, Wake Forest Baptist Medical Center, Winston-Salem, NC, 27157, USA.,Section on Gastroenterology, University of Maryland Medical Center, Baltimore, MD, 21210, USA
| | - Paula Stuart
- Section on Gastroenterology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - Carl Westcott
- Section on Gastroenterology, Department of Surgical Services, Wake Forest Baptist Medical Center, Winston-Salem, NC, 27157, USA
| | - Kenneth L Koch
- Section on Gastroenterology, Department of Surgical Services, Wake Forest Baptist Medical Center, Winston-Salem, NC, 27157, USA. .,Section on Gastroenterology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, 27157, USA.
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Jagtap N, Kalapala R, Reddy DN. Assessment of Pyloric Sphincter Physiology Using Functional Luminal Imaging Probe in Healthy Volunteers. J Neurogastroenterol Motil 2020; 26:391-396. [PMID: 32606259 PMCID: PMC7329157 DOI: 10.5056/jnm19200] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 02/06/2020] [Accepted: 03/22/2020] [Indexed: 01/17/2023] Open
Abstract
Background/Aims The functional luminal imaging probe (FLIP) can measure tissue distensibility and geometric changes through volumetric distention. The esophagogastric junction has been well studied using EndoFLIP, studies on pylorus are lacking. We aim to study biomechanical properties of pylorus using EndoFLIP to create normative data. Methods We performed a prospective study of 20 healthy volunteers (ages, 18-54 years; 10 men) who underwent pylorus evaluation using 12- cm FLIP placed across the pyloric sphincter. FLIP data were analyzed using FLIP planimetry plots at baseline and after administration of hyoscine butyl bromide injection. Results The median pylorus distensibility index (P-DI) was 8.37 mm2/mmHg (interquartile range, 4.22-13.04 mm2/mmHg) at 40 mL balloon volume. The 90th percentile at 40 mL balloon for P-DI was 14.89 mm2/mmHg, for cross-sectional area was 244.20 mm2/mmHg, and diameter and pressure were 17.58 mm and 48.84 mmHg, respectively. There was significant increase in P-DI after administration of hyoscine butyl bromide injection (P < 0.05). Conclusion The normative values can be used as reference values for pyloric distensibility. This reference can be used in studies of related to pyloric diseases such as gastroparesis.
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Affiliation(s)
- Nitin Jagtap
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Rakesh Kalapala
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
| | - D Nageshwar Reddy
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
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Vosoughi K, Ichkhanian Y, Jacques J, Aadam AA, Benias PC, Law R, Hasler WL, Canakis A, Ragi O, Triggs J, Bowers N, Brewer Gutierrez OI, Kumbhari V, Kalloo AN, Bulat RS, Pandolfino JE, Khashab MA. Role of endoscopic functional luminal imaging probe in predicting the outcome of gastric peroral endoscopic pyloromyotomy (with video). Gastrointest Endosc 2020; 91:1289-1299. [PMID: 32035074 DOI: 10.1016/j.gie.2020.01.044] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 01/22/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Endoluminal functional luminal imaging probe (EndoFLIP) is an imaging tool that measures the physiologic characteristics of GI sphincters. In this study, we used EndoFLIP to evaluate the association between the pyloric physiologic measurements and the clinical outcomes of gastric peroral endoscopic myotomy (G-POEM) in patients with refractory gastroparesis. METHODS Thirty-seven patients from 5 centers who underwent G-POEM for management of refractory gastroparesis and had EndoFLIP measurements were evaluated. Cross-sectional area (CSA), balloon pressure, and the distensibility index (DI) of the pylorus were evaluated by EndoFLIP at 40 mL and 50 mL balloon fills before and after G-POEM. One-year clinical success and change in gastric emptying study 3 months after the G-POEM procedure were compared with the EndoFLIP measurements. RESULTS Clinical success was achieved in 26 (70%) patients. Post-G-POEM CSA and DI were significantly higher in the clinical success group with both 40-mL volume distension (CSA: 89.9 ± 64.8 vs 172.5 ± 71.9 mm2, P =.003; DI: 5.8 ± 4.4 vs 8.8 ± 6.1 mm2/mm Hg, P =.043) and 50-mL volume distention (CSA: 140.1 ± 89.9 vs 237.5 ± 80.3 mm2, P =.003; DI: 5.6 ± 3.3 vs 9.9 ± 6.6 mm2/mm Hg, P =.049). CSA using 40-mL volume distention with an area under the curve of 0.83 yielded a specificity of 91% and a sensitivity of 71% at a cutoff point of 154 mm2. CONCLUSIONS Post-G-POEM CSA of the pylorus is associated with clinical success and improvement in a gastric emptying scan after G-POEM. EndoFLIP measurements of the pylorus have the potential to be used as a tool to predict the clinical outcome of G-POEM.
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Affiliation(s)
- Kia Vosoughi
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Yervant Ichkhanian
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Jérémie Jacques
- Gastroenterology Department, Dupuytren University Hospital, Limoges, France
| | - A Aziz Aadam
- Division of Gastroenterology, Northwestern University, Chicago, Illinois, USA
| | - Petros C Benias
- Division of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, Northwell Health System, New Hyde Park, New York, USA
| | - Ryan Law
- Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan, USA
| | - William L Hasler
- Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan, USA
| | - Andrew Canakis
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Olivier Ragi
- Gastroenterology Department, Dupuytren University Hospital, Limoges, France
| | - Joseph Triggs
- Division of Gastroenterology, Northwestern University, Chicago, Illinois, USA
| | - Nicole Bowers
- Division of Gastroenterology, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Vivek Kumbhari
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Anthony N Kalloo
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Robert S Bulat
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - John E Pandolfino
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
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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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How Taking into Account the Pyloric Tonus Contributes to Treatment Success While Administering Gastric "Botulinum Toxin A" for Weight Loss. Obes Surg 2020; 30:3365-3369. [PMID: 32405906 DOI: 10.1007/s11695-020-04556-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
PURPOSE To analyze how considering the structure of normotonic pylorus (NP) or hypotonic pylorus (HP) contributes to treatment success in patients administered gastric botulinum toxin A for weight loss. MATERIALS AND METHODS We measured body mass indexes (BMIs) of the patients who applied for gastric botulinum toxin A (BTA) for weight loss, before and 6 months after the procedure. The patients' pylori were classified as normotonic pylorus (NP) if, during endoscopy, they had a normal peristaltic motion and was closing completely, and as hypotonic pylorus if they were not closing properly or were aperistaltic. We compared the patients' mean pre-operative and 6-month post-operative BMIs. The groups were compared using the chi-square test where a p ˂ 0.05 was considered significant. RESULTS The study included 178 patients administered gastric BTA. In the assessment made without considering the pyloric structure, the mean BMI decreased from 34.76 ± 7.65 to 33.09 ± 7.80 kg/m2, while the difference was not statistically significant (p ˂ 0.06). Conversely, in the analysis performed considering the structure of pylorus, the mean pre-operative BMI of the 45 patients with HP structure was 35.16 ± 7.07 kg/m2 which decreased to 35.11 ± 7.03 kg/m2 6 months after the procedure; hence, the difference was not statistically significant (p ˂ 0.7). The mean pre-operative BMI of the 133 patients with NP structure, 34.63 ± 7.84 kg/m2, decreased to 32.40 ± 8.05 kg/m2 6 months after the procedure and the difference was statistically significant (p ˂ 0.05)*. CONCLUSION We advise to be selective in BTA administration and to administer BTA to the patients who, endoscopically, have a NP structure.
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Desprez C, Melchior C, Wuestenberghs F, Huet E, Zalar A, Jacques J, Leroi AM, Gourcerol G. Pyloric distensibility measurement after gastric surgery: Which surgeries are associated with pylorospasm? Neurogastroenterol Motil 2020; 32:e13790. [PMID: 31916346 DOI: 10.1111/nmo.13790] [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: 08/08/2019] [Accepted: 12/13/2019] [Indexed: 01/19/2023]
Abstract
BACKGROUND AND STUDY AIMS History of gastric surgery is found in 10% of patients with gastroparesis, and vagal lesion is often suspected to be the cause of pylorospasm. Recently, pyloric distensibility measurement using the EndoFLIP® system showed that pylorospasm was present in 30%-50% of gastroparetic patients. Our objective was to assess whether pylorospasm, diagnosed using EndoFLIP® system was observed in three different types of gastric surgeries: antireflux surgery, sleeve gastrectomy, and esophagectomy. PATIENTS AND METHODS Pyloric distensibility and pressure were measured using the EndoFLIP® system in 43 patients from two centers (18 antireflux surgery, 16 sleeve gastrectomy, and nine esophagectomy) with dyspeptic symptoms after gastric surgery, and in 21 healthy volunteers. Altered pyloric distensibility was defined as distensibility below 10 mm2 /mm Hg as previously reported. RESULTS Compared to healthy volunteers (distensibility: 25.2 ± 2.4 mm2 /mm Hg; pressure: 9.7 ± 4.4 mm Hg), pyloric distensibility was decreased in 61.1% of patients in the antireflux surgery group (14.5 ± 3.4 mm2 /mm Hg; P < .01) and 75.0% of patients in the esophagectomy group (10.8 ± 2.1 mm2 /mm Hg; P < .05), while pyloric pressure was only increased in the antireflux surgery group (18.9 ± 2.2 mm Hg; P < .01). Pyloric distensibility and pressure were similar in healthy volunteers and in sleeve gastrectomy (distensibility: 20.3 ± 3.8 mm2 /mm Hg; pressure: 15.8 ± 1.6 mm Hg) groups, with decreased pyloric distensibility affecting 18.7% of sleeve gastrectomy patients. CONCLUSION Antireflux surgery and esophagectomy were associated with pylorospasm although pylorospasm was not found in all patients. Sleeve gastrectomy was not associated with altered pyloric distensibility nor altered pyloric pressure.
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Affiliation(s)
- Charlotte Desprez
- Physiology Department, Rouen University Hospital, Rouen, France.,Nutrition, Brain and Gut Laboratory, INSERM Unit 1073, Rouen University Hospital, Rouen, France
| | - Chloé Melchior
- Nutrition, Brain and Gut Laboratory, INSERM Unit 1073, Rouen University Hospital, Rouen, France.,Hepatogastroenterology Department, Rouen University Hospital, Rouen, France
| | - Fabien Wuestenberghs
- Physiology Department, Rouen University Hospital, Rouen, France.,Nutrition, Brain and Gut Laboratory, INSERM Unit 1073, Rouen University Hospital, Rouen, France
| | - Emmanuel Huet
- Nutrition, Brain and Gut Laboratory, INSERM Unit 1073, Rouen University Hospital, Rouen, France.,Digestive Surgery Department, Rouen University Hospital, Rouen, France
| | - Alberto Zalar
- Hepatogastroenterology Department, Rouen University Hospital, Rouen, France
| | - Jérémie Jacques
- Hepatogastroenterology Department, Limoges University Hospital, Limoges, France
| | - Anne-Marie Leroi
- Physiology Department, Rouen University Hospital, Rouen, France.,Nutrition, Brain and Gut Laboratory, INSERM Unit 1073, Rouen University Hospital, Rouen, France.,Clinical Investigation Center, INSERM 0204, Rouen University Hospital, Rouen, France
| | - Guillaume Gourcerol
- Physiology Department, Rouen University Hospital, Rouen, France.,Nutrition, Brain and Gut Laboratory, INSERM Unit 1073, Rouen University Hospital, Rouen, France.,Clinical Investigation Center, INSERM 0204, Rouen University Hospital, Rouen, France
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Bapaye A, Dubale NA. Gastric per-oral endoscopic myotomy: Indications, technique, outcomes, and future directions. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2020. [DOI: 10.18528/ijgii200014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Amol Bapaye
- Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, Pune, India
| | - Nachiket A. Dubale
- Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, Pune, India
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Abstract
The field of third space endoscopy (TSE), also called submucosal endoscopy using a mucosal flap valve, allows secure access to the submucosal and deeper layers of the gastrointestinal tract without the risk of a full-thickness perforation. Since the first description of per-oral endoscopic myotomy (POEM) for the treatment of achalasia cardia 10 years ago, this field has expanded rapidly. Several new procedures, submucosal tunneling endoscopic resection, gastric-POEM, Zenker POEM, per-rectal endoscopic myotomy, diverticular POEM, and recanalization for complete esophageal obstruction (per-oral endoscopic tunneling for restoration of the esophagus), have been performed. All TSE procedures employ a similar technique-after a mucosal incision, a submucosal tunnel is created, a myotomy is performed, or a subepithelial tumor is resected distal to the site of mucosal incision, after which the mucosal incision is closed. Potential indications for TSE include resection of subepithelial tumors in the esophagus, gastroesophageal junction, or stomach; refractory gastroparesis; Zenker diverticulum; Hirschsprung disease or other forms of megacolon; and recanalization for complete esophageal obstruction. Data are currently available for POEM, submucosal tunneling endoscopic resection, and gastric-POEM, although mainly in the form of retrospective studies, and randomized trials and long-term follow-up data are limited. Submucosal endoscopy has an excellent safety profile with very few intraoperative adverse events, the majority being related to insufflation, although bleeding, perforation, and sepsis have been reported. TSE procedures require special training and have demonstrated a learning curve.
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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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Parkman HP, Orthey P, Maurer AH. Gastric Motility. ENCYCLOPEDIA OF GASTROENTEROLOGY 2020:598-612. [DOI: 10.1016/b978-0-12-801238-3.11092-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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49
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Pasricha PJ. Pyloric interventions for gastroparesis: Does a "flippant" approach help us select the right patients? Gastrointest Endosc 2019; 90:761-762. [PMID: 31635714 DOI: 10.1016/j.gie.2019.06.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 06/27/2019] [Indexed: 12/11/2022]
Affiliation(s)
- Pankaj J Pasricha
- Department of Medicine and Neurosciences, Center for Neurogastroenterology, Amos Food Body and Mind Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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50
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Chen HM, Li BW, Li LY, Xia L, Chen XB, Shah R, Abdelfatah MM, Jain A, Cassani L, Massaad J, Keilin S, Cai Q. Functional lumen imaging probe in gastrointestinal motility diseases. J Dig Dis 2019; 20:572-577. [PMID: 31498966 DOI: 10.1111/1751-2980.12818] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 08/19/2019] [Accepted: 09/06/2019] [Indexed: 12/11/2022]
Abstract
Dysfunction of gastrointestinal (GI) sphincters, including the lower esophageal sphincter (LES) at the esophagogastric junction (EGJ) and the pyloric sphincter, plays a vital role in GI motility disorders, such as achalasia, gastroesophageal reflux disease (GERD), gastroparesis, and fecal incontinence. Using multi-detector high-resolution impedance planimetry, the functional luminal imaging probe (FLIP) system measures simultaneous data on tissue distensibility and luminal geometry changes in the sphincter in a real-time manner. In this review we focus on the emerging data on FLIP, which can be used as an innovative diagnostic method during endoscopic or surgical procedures in GI motility disorders. Subsequent large, prospective, standardizing studies are needed to validate these findings before it can be put to routine clinical use.
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Affiliation(s)
- Hui Min Chen
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA.,Division of Gastroenterology and Hepatology, Shanghai Institute of Digestive Disease, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Bai Wen Li
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA.,Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Lian Yong Li
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA.,Department of Gastroenterology, The People's Liberation Army 306th Hospital, Beijing, China
| | - Liang Xia
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA.,Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Xiang Bo Chen
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA.,Department of Endoscopy, Quanzhou First Hospital Affiliated to Fujian Medical University, Quanzhou, Fujian Province, China
| | - Rushikesh Shah
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Mohamed M Abdelfatah
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Anand Jain
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Lisa Cassani
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA.,Division of Digestive Diseases, Department of Medicine, Atlanta Veterans Affairs Medical Center, Decatur, GA, USA
| | - Julia Massaad
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Steve Keilin
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Qiang Cai
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA
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