Gastric Peroral Endoscopic Myotomy Research Articles

The Impact of Pyloric Directed Therapy for Gastroparesis

Gastroparesis presents with nausea, early satiety, vomiting, bloating, distention, and abdominal pain and is diagnosed by documenting delayed passage of contents from the stomach to the intestines in the absence of mechanical obstruction. Several factors contribute to gastroparesis pathophysiology. Pylorospasm, or increased pyloric contractility, is present in many patients and may be a target for therapy of cases of refractory gastroparesis when medical management is insufficient. Pylorus-directed interventions including botulinum toxin injections, pneumatic balloon dilation, stenting, surgical pyloroplasty, and gastric per-oral endoscopic myotomy are increasingly employed to treat selected patients with gastroparesis who are unresponsive to medications.

Prognostic Value of Pre-Operative Intragastric Meal Distribution in Gastric Emptying Scintigraphy for Long-Term Success of Gastric Peroral Endoscopic Myotomy in Gastroparesis

Background and aimsGastric emptying scintigraphy (GES) is the gold standard for the diagnosis of gastroparesis. However, data are lacking regarding the prognostic value of pre-operative intragastric meal distribution during GES, in patients undergoing gastric peroral endoscopic myotomy (GPOEM) for gastroparesis. This study investigated the association of GES morphologic parameters and the long-term clinical success of G-POEM. MethodsThis retrospective study included patients who underwent G-POEM for refractory gastroparesis in a tertiary center with preoperative GES data. Intragastric meal distribution was measured using the proximal to distal count ratio (PDCR) at 0, 1, 2 and 4 hours (h), and the retention index (RI) was calculated. Clinical success was defined as a decrease of at least 50% in the post-G-POEM Gastroparesis Cardinal Symptom Index (GCSI) total score. ResultsIn total, 77 patients were included with a mean follow-up of 40.14 months. Clinical success was observed in 54.55% of patients. The RI was not associated with clinical success. Only PDCR at 0h (PDCR0) was associated with clinical success. In univariate analysis, the median PDCR0 was 6.0 (IQR 5.59) in patients with clinical success and 4.29 (IQR 4.51) in patients with clinical failure (p=0.019). In multivariate analysis, PDCR0 > 5.25 was associated with clinical success (HR = 4.36 [1.55;12.26], p=0.00524). ConclusionsThis study suggests that in patients with gastroparesis, High PDCR0 value (suggestive for a preferential fundic meal distribution) during preoperative GES is associated with long-term clinical response to G-POEM.

Efficacy and Safety of Gastric Per-Oral Endoscopic Myotomy (G-POEM): A Systematic Review and Meta-Analysis.

Gastric per-oral endoscopic myotomy (G-POEM) is an innovative treatment that has become increasingly utilized for patients with refractory gastroparesis. The aim of this systematic review and meta-analysis was to evaluate the safety and effectiveness of G-POEM for the treatment of gastroparesis. Individualized search strategies were developed through February 2021 in accordance with the PRISMA and MOOSE guidelines. This meta-analysis was performed by calculating pooled proportions and mean difference preprocedure and postprocedure with rates estimated using random effects models. Measured outcomes included technical success, clinical success, improvement in gastroparesis cardinal symptom index (GCSI), change in gastric emptying rate, alterations in impedance planimetry (functional lumen imaging probe [FLIP]) assessment, and adverse events. A total of 20 studies (n=797 patients; 67.41% female) were included. The mean age was 48.92±11.61 y, with an average duration of 4.24±1.11 y since gastroparesis diagnosis. Technical success was 98.47% [(95% CI: 97.14, 99.19);I2=0.00] with a mean myotomy length of 3.78±1.16cm. In terms of clinical success, mean preprocedure GCSI scores were 3.38±0.37 and improved significantly postprocedure [weighted mean difference -1.56 (95% CI: -1.89 to -1.24); I2=82.53; P<0.001]. Gastric retention after 4 hours demonstrated ~50% improvement (preprocedure 43.08±9.24% versus postprocedure 22.97±10.19%; P<0.001). FLIP assessment with 40mL and 50mL balloons demonstrated a significant increase in diameter, distensibility index, and cross-sectional area postprocedure (all P<0.05). Procedure-associated adverse events occurred among 10.92% [(95% CI 5.09 to 19.32); I2=82.85] of patients. G-POEM appears safe and highly effective for the treatment of patients with refractory gastroparesis regardless of symptom predominance or etiology.

Quantification of interstitial cells of Cajal and fibrosis during gastric per-oral endoscopic myotomy and its association with clinical outcomes.

Background and study aims Alterations to interstitial cells of Cajal (ICC) and collagen fibrosis have been implicated in the pathogenesis of gastroparesis. We aimed to evaluate the feasibility and safety of pyloric muscle sampling during gastric peroral endoscopic myotomy (G-POEM) and the association between pyloric ICC density and degree of fibrosis with clinical outcomes. Patients and methods This was a single-center prospective study of gastroparetic patients who underwent G-POEM and intraprocedural pyloric muscle biopsies between January 2022 and April 2023. ICC count was estimated using CD117 stain and trichome for collagen fibrosis. Clinical response to G-POEM was defined as an improvement of ≥ 1 point on the Gastroparesis Cardinal Symptom Index. Results Fifty-six patients (median age 60 years, 71.4% women) underwent G-POEM (100% technical success; 71.4% clinical response). ICC depletion (< 10/high-power field) and fibrosis were encountered in 70.4% and 75% of the cases, respectively. There was no difference in mean ICC count between G-POEM responders vs. non-responders (7±3.6 vs. 7.7±3.3; P = 0.9). There was no association between ICC density or degree of fibrosis with the etiology of gastroparesis, duration of symptoms, gastric emptying rate, or pyloric impedance planimetry. Patients who did not respond to G-POEM had a significantly higher degree of moderate/severe fibrosis when compared with those who responded (81.3% vs. 25%; P = 0.0002). Conclusions Pyloric muscle biopsies during G-POEM was feasible and safe. ICC depletion and pyloric muscle fibrosis are common in gastroparetic patients. The degree of fibrosis may be related to pyloric dysfunction and clinical response to G-POEM. Additional studies are needed to confirm these results.

Applications of gastric peroral endoscopic myotomy in the treatment of upper gastrointestinal tract disease.

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.

Gastric peroral endoscopic myotomy versus botulinum toxin injection for the treatment of refractory gastroparesis: results of a double-blind randomized controlled study.

Gastric peroral endoscopic myotomy (G-POEM) is a promising technique for treating refractory gastroparesis. We present the first double-blind randomized study comparing the clinical efficacy of G-POEM versus pyloric botulinum toxin injection (BTI). This randomized study, conducted in two expert centers, enrolled patients with refractory gastroparesis, medically managed for >6 months and confirmed by gastric emptying scintigraphy (GES), into two groups, G-POEM versus BTI, with follow-up of 1 year. The primary end point was the 3-month clinical efficacy, defined as a >1-point decrease in the mean Gastroparesis Cardinal Symptom Index (GCSI) score. Secondary end points were: 1-year efficacy, GES evolution, adverse events, and quality of life. 40 patients (22 women; mean age 48.1 [SD 17.4]), with mean symptom duration of 5.8 (SD 5.7) years, were randomized. Etiologies included idiopathic (n=18), diabetes (n=11), postoperative (n=6), and mixed (n=4). G-POEM showed a higher 3-month clinical success than BTI (65% vs. 40%, respectively; P=0.10), along with non-significantly higher 1-year clinical success (60% vs. 40%, respectively) on intention-to-treat analysis. The GCSI decreased in both groups at 3 months and 1 year. Only three minor adverse events occurred in the G-POEM group. The GES improvement rate was 72% in the G-POEM group versus 50% in the BTI group (non-significant). G-POEM seems to have a higher clinically relevant success rate than BTI, but this was not statistically demonstrated. This study confirms the interest in treatments targeting the pylorus, either mechanically or chemically, for managing refractory gastroparesis.

Using Botulinum Toxin for the Treatment of Gastroparesis (GP) for the selection of Patients with Higher Clinical Success, Improved Quality of Life (QOL), and Improved Social Functioning Post Gastric Peroral Endoscopic Myotomy (GPOEM)

Background/Objective:While G-POEM remains an effective and exciting treatment for GP patients, predictors of clinical success remain poorly characterized. Botox injection of the pylorus prior to committing to GPOEM can help differentiate those who might have a favorable clinical response to this procedure in patients with GP.&#x0D; Methods:To evaluate the utility of Botox injection prior to G-POEM, 124 patients with clinically diagnosed GP who underwent a GPOEM were assessed in this retrospective cohort study. All G-POEM procedures were conducted at a single center and were completed between February 2018 and May 2023. Patients who had received intrapyloric Botox injection (n=79) had QoL and clinical success rates compared to patients who received other treatment options (n=45). Results were assessed at 1-, 3-, 6-, 12-, 24-, 36-, 48-months post G-POEM.&#x0D; Results:When assessing symptom severity, the difference between the change in GCSI values for Botox patients and patients receiving other prior therapy was statistically significant at 6 months post-GPOEM; +1.27 for Botox patients vs +0.55 for other treatments (p-value of 0.03). At this 6-month checkpoint, 64% of the Botox group achieved clinical success compared to 37.5% for the other treatment group. When comparing QoL, intrapyloric Botox injection has statistically significant improvements in SF-36 total score at 1, 3-, 6-, 12-, and 36-months post G-POEM, while patients receiving other treatments had no statistically significant improvements in their SF-36 total scores.&#x0D; Conclusion:We hypothesize that clinical improvement on pre GPOEM Botox selects patients with a higher component of pyloric spasm who end up responding more favorably to G-POEM.&#x0D; Scientific/Clinical/Policy Impact and Implications:Intrapyloric Botox injection is technically feasible in almost all patients with GP and does not require special expertise, training, or equipment; therefore, this should be strongly considered prior to referring a patient for G-POEM.

Erratum

Gastrointestinal symptoms related to antireflux surgery are result of either an incompetent gastroesophageal valve, a supra-therapeutic valve or other complications of anti-reflux surgery such as decreased gastric accommodation, rapid gastric emptying, gastroparesis, paraesophageal hernia, or exacerbation of another undiagnosed motility disorder. Here, we reviewed a diagnostic approach for these symptoms which starts with detailed history and a tailored approach in use of diagnostic tests and empirical treatment to aid in diagnosis. In treatment for these symptoms, a conservative approach with lifestyle modifications should be employed first and repeat surgical procedure should be reserved as the last option. Of the emerging endoscopic therapies for symptoms refractory to medical therapy, gastric per-oral endoscopic myotomy is effective in improving gastric emptying and related symptoms.

Role of gastric peroral endoscopic myotomy (GPOEM) in chronic gastroparesis management after pancreas transplantation.

Gastroparesis is a common complaint among patients with diabetes. Symptoms tend to improve following successful pancreas transplantation (PTx), but persist despite euglycemia in a subset of patients. We aimed to assess the benefit of gastric peroral endoscopic myotomy (G-POEM) in persistent gastroparesis following PTx. This was a single center retrospective review of all patients who underwent G-POEM for persistent gastroparesis following PTx. Patient demographics, pre and post procedure perception of symptom severity according to the patient assessment of upper gastrointestinal symptoms severity index (PAGI-SYM), gastroparesis cardinal symptom index (GCSI) score, and 36-item short form survey (SF36) score along with gastric emptying scintigraphy (GES) were analyzed. Seven PTx recipients underwent G-POEM for persistent gastroparesis symptoms. The majority were female. All reported nausea/vomiting, abdominal pain, bloating, and post prandial fullness prior to G-POEM. The post procedure survey scores improved in all patients although this was not significant. The improvement in gastric emptying on GES was statistically significant. G-POEM is a relatively new treatment option for gastroparesis. While it requires specialized proceduralist and training, we have documented improvement in the management of symptoms. With increasing experience, we anticipate more significant benefit in post PTx patients with persistent symptoms of gastroparesis undergoing G-POEM.

S1871 Meta-Analysis on Gastric Per-Oral Endoscopic Myotomy as an Emerging Technique for Refractory Gastroparesis

S1871 Meta-Analysis on Gastric Per-Oral Endoscopic Myotomy as an Emerging Technique for Refractory Gastroparesis

P.28: Role of gastric peroral endoscopic myotomy (G-POEM) in gastroparesis management after pancreas transplantation

P.28: Role of gastric peroral endoscopic myotomy (G-POEM) in gastroparesis management after pancreas transplantation

S1891 Long Term Outcomes (≥ 3 Years) Following Gastric Peroral Endoscopic Myotomy for Gastroparesis: A Systematic Review and Meta-Analysis

S1891 Long Term Outcomes (≥ 3 Years) Following Gastric Peroral Endoscopic Myotomy for Gastroparesis: A Systematic Review and Meta-Analysis

S1304 Efficacy and Safety of Gastric Peroral Endoscopic Myotomy for Refractory Gastroparesis

S1304 Efficacy and Safety of Gastric Peroral Endoscopic Myotomy for Refractory Gastroparesis

Gastric peroral endoscopic myotomy using a novel bipolar blade and the navigational tunnel technique

Video 1Demonstration of gastric peroral endoscopic myotomy using a novel bipolar blade and the navigational tunnel technique.

Research hotspots and trend of a emerging novel endoscopic technique of peroral endoscopic myotomy from 2010 to 2022: A bibliometric analysis.

Peroral endoscopic myotomy (POEM), which has been used to treat achalasia and other esophageal motility disorders for the past 10 years, has proven to be secure and efficient. Every year, more and more essays on this subject are published. We sought to investigate the global scientific outputs and hotspots of POEM produced by various nations, organizations, and authors. From 2010 to October 2022, there were 875 papers on POEM that were found in the Web of Science Core database. The bibliometric visualization analyses of nations/regions, institutions, authors, journals, references, and keywords were conducted by CiteSpace V.5.8.R3. Eight hundred seventy-five publications were included in this analysis. With 68 publications, Inoue H had the highest output. While Showa University in Japan was the most productive institution, the United States was the most productive nation. Among the journals, Surgical Endoscopy published the highest number of articles, followed by Gastrointestinal Endoscopy and Endoscopy. The top 10 keywords that appeared most frequently were achalasia, peroral endoscopic myotomy, POEM, myotomy, esophageal achalasia, dysphagia, heller myotomy, endoscopy, gastroparesis and peroral endoscopic myotomy. Seven frontiers, including meta-analysis, high-resolution esophageal manometry, geriatric patient, third space endoscopy, adverse event, endoscopic submucosal dissection, and gastric peroral endoscopic myotomy, had an impact on future research on POEM. The previous 10 years have seen a considerable rise in POEM research, and this trend will continue. The most recent research frontiers, which require more attention, are meta-analysis, high-resolution esophageal manometry, geriatric patient, third space endoscopy, adverse event, and gastric peroral endoscopic myotomy.

Modified gastric-peroral endoscopic myotomy with sleeve release in a case of severe gastric sleeve stenosis

Video 1Modified gastric-peroral endoscopic myotomy with sleeve release in a case of severe gastric sleeve stenosis.

Achalasia Combined with Idiopathic Gastroparesis Treated with Peroral Endoscopic Myotomy and Gastric Peroral Endoscopic Myotomy in a Single Procedure.

Achalasia Combined with Idiopathic Gastroparesis Treated with Peroral Endoscopic Myotomy and Gastric Peroral Endoscopic Myotomy in a Single Procedure.

Imaging in Gastroparesis: Exploring Innovative Diagnostic Approaches, Symptoms, and Treatment.

Gastroparesis (GP) is a chronic disease characterized by upper gastrointestinal symptoms, primarily nausea and vomiting, and delayed gastric emptying (GE), in the absence of mechanical GI obstruction. The underlying pathophysiology of GP remains unclear, but factors contributing to the condition include vagal nerve dysfunction, impaired gastric fundic accommodation, antral hypomotility, gastric dysrhythmias, and pyloric dysfunction. Currently, gastric emptying scintigraphy (GES) is considered the gold standard for GP diagnosis. However, the overall delay in GE weakly correlates with GP symptoms and their severity. Recent research efforts have focused on developing treatments that address the presumed underlying pathophysiological mechanisms of GP, such as pyloric hypertonicity, with Gastric Peroral Endoscopic Myotomy (G-POEM) one of these procedures. New promising diagnostic tools for gastroparesis include wireless motility capsule (WMC), the 13 carbon-GE breath test, high-resolution electrogastrography, and the Endoluminal Functional Lumen Imaging Probe (EndoFLIP). Some of these tools assess alterations beyond GE, such as muscular electrical activity and pyloric tone. These modalities have the potential to characterize the pathophysiology of gastroparesis, identifying patients who may benefit from targeted therapies. The aim of this review is to provide an overview of the current knowledge on diagnostic pathways in GP, with a focus on the association between diagnosis, symptoms, and treatment.

Efficacy and safety of gastric per-oral endoscopic myotomy (GPOEM) in lung transplant patients with refractory gastroparesis: a systematic review and meta-analysis.

Post-lung transplant gastroparesis is a frequent debilitating complication of lung transplant recipients, as it can increase the risk for gastro-esophageal reflux disease and subsequent graft dysfunction. We performed a systematic review and meta-analysis to evaluate the efficacy and safety of GPOEM in lung transplant patients with refractory gastroparesis. The present systematic review and meta-analysis wer performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. We selected studies that analyzed the gastroparesis cardinal symptom index (GCSI) before and after the procedure to verify the efficacy of GPOEM. Random-effects model was used and the analysis was performed with STATA 17. Four observational studies (one conference abstract) with 104 patients were included in the meta-analysis. Prior treatments for gastroparesis included prokinetic agents and botulinum toxin in 78% (78/104) and 66.7% (66/99), respectively. Pooled estimate for clinical efficacy of GPOEM was 83% (95% CI 76%-90%). The pooled mean reduction in GCSI following the procedure was -2.01 (-2.35, -1.65, p = 0.014). Three studies reported statistically significant improvement of gastro-esophageal retention or emptying in the post-GPOEM period. 30-day post-operative complications included minor or major bleeding (11.6%), severe reflux (1.2%), and pyloric stenosis (1.2%) requiring re-intervention. 90-day all-cause mortality was 2.6% with one patient dying from severe allograft rejection. Our study showed that GPOEM is an effective and safe strategy for lung transplant patients with refractory gastroparesis and should be considered as a therapeutic strategy in this population. Larger multicenter trials are needed in the future to further evaluate the effect of GPOEM on allograft function and rates of rejection.

Long-term outcomes (≥3 years) after gastric peroral endoscopic myotomy for refractory gastroparesis: a systematic review and meta-analysis

Long-term outcomes (≥3 years) after gastric peroral endoscopic myotomy for refractory gastroparesis: a systematic review and meta-analysis