Gastric Peroral Endoscopic Pyloromyotomy Research Articles

Gastric Peroral Endoscopic Pyloromyotomy for Infants With Congenital Hypertrophic Pyloric Stenosis: Ready for Prime Time?

1Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA. Correspondence: Petar Mamula, MD. E-mail: [email protected].

Gastric peroral endoscopic pyloromyotomy (G-POEM) in patients with refractory gastroparesis: a review.

Gastric peroral endoscopic pyloromyotomy (G-POEM or POP) is an endoscopic therapeutic modality for treatment of refractory gastroparesis. Since the first case reported in 2013, there are more than 200 papers published on G-POEM. In this narrative review, we summarize the short-term and long-term outcomes and review other important studies. The technical success rate is 100% and the short-term (within 1 year) success rate is about 50-80%. The procedure time is between 50 and 70 min while the average length of hospital stay was 2-3 days. The adverse event rate was around 10%. Few patients need further intervention. Three studies showed that at the 4-year follow-up, the response to G-POEM was durable, but there was a yearly recurrence rate of 13% or more. Redo G-POEM is feasible and can be of benefit for some patients. Most of the studies showed that long duration of illness is associated with poor outcomes. However, reliable predictors for successful outcomes are still unknown. Current literature indicates G-POEM is superior to gastric electric stimulator and surgical pyloroplasty. Endoflip has been used at G-POEM to predict the outcome, but the result is very preliminary. A recent sham study confirms the short-term efficacy of G-POEM. G-POEM is safe and about 50% of patients can be discharged to home on the same day. G-POEM allows for direct biopsy of the gastric muscle, which is the location of the pacemaker cells, the interstitial cells of Cajal; therefore, G-POEM may provide a new path for further research on the pathogenesis of gastroparesis.

Gastric peroral endoscopic pyloromyotomy for the treatment of congenital hypertrophic pyloric stricture in an infant with a self-made bite block.

Gastric per-oral endoscopic myotomy (G-POEM) is reported to be a promising treatment for refractory gastroparesis, on the other hand, it is also an effective treatment for congenital hypertrophic pyloric stenosis (CHPS). Here, we want to report a case in which G-POEM was performed in an infant with CHPS.

S1613 Short Term Outcomes of Gastric Per Oral Endoscopic Pyloromyotomy (GPOEM) Seven Years Ago and Now

S1613 Short Term Outcomes of Gastric Per Oral Endoscopic Pyloromyotomy (GPOEM) Seven Years Ago and Now

A New Paradigm Shift in Gastroparesis Management.

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.

Clip-anchoring technique: a fast, cheap, and efficient way to close a gastric peroral endoscopic pyloromyotomy tunnel.

Clip-anchoring technique: a fast, cheap, and efficient way to close a gastric peroral endoscopic pyloromyotomy tunnel.

Navigational tunnel technique for gastric peroral endoscopic pyloromyotomy: getting straight to the point (pylorus).

Background and AimsGastric peroral endoscopic pyloromyotomy (G-POEM) is emerging as a treatment option for patients with gastroparesis. The most technically difficult part of the procedure is creating a submucosal tunnel in the gastric antrum, which can be directionally challenging. We describe a novel navigational tunneling method that guides submucosal dissection in the direction of the pylorus and helps to identify the pyloric landmarks.MethodsConsecutive patients from September to December 2020 who underwent G-POEM for symptomatic gastroparesis were included. All cases were confirmed by prolonged gastric emptying study. The navigational tunnel technique was performed as follows: (1) mucosal cautery markings were made to outline the tunnel starting 3 to 4 cm proximal to the pylorus, (2) submucosal injection was done at the level of the pylorus and extended backward to the incision point, and (3) submucosal dissection was carried out after the prior submucosal injection straight to the pylorus.ResultsSix patients with gastroparesis underwent G-POEM with the navigational tunneling technique. The average time for submucosal injection was 2 minutes and 42 seconds, and the average tunnel time was 15 minutes and 36 seconds. There were no adverse events. All patients reported significant improvement (50%-85%) in symptoms.ConclusionsThis novel navigational tunneling technique appears to guide and facilitate G-POEM by providing a visual path for submucosal dissection straight to the pylorus. It may increase efficiency, decreasing the need to repeatedly exit the tunnel to check direction and preventing nonproductive wandering. It may also help identify the pyloric ring within the tunnel.

Beyond Metoclopramide for Gastroparesis

Beyond Metoclopramide for Gastroparesis

ID: 3527213 THIRD SPACE ENDOSCOPY AFTER FORMAL ENDOSCOPY ADVANCED FELLOWSHIP TRAINING IN THE US: ONE YEAR LINEAR FOLLOW UP OF INDEPENDENT PRACTICE

Third space endoscopy includes peroral endoscopic myotomy (POEM) and gastric peroral endoscopic pyloromyotomy (GPOEM). Very few advanced endoscopy fellowships offer comprehensive training in third space endoscopy in addition to ERCP and EUS, given the risk associated with these procedures. Multiple studies have reported the learning curve for POEM. We followed a single trainee experience following formal third space endoscopy training.

Refeeding syndrome: a fatal adverse event of gastric peroral endoscopic pyloromyotomy

A 61-year-old woman with a history of chronic obstructive pulmonary disease and body mass index of 24 presented with recurrent hospital admissions for intractable nausea, vomiting, and weight loss of 40 pounds over the previous 3 months. The results of an extensive workup including upper and lower endoscopy, and CT of the chest, abdomen, and pelvis, were negative. A gastric emptying study demonstrated severe idiopathic gastroparesis. Medical treatment with metoclopramide (Reglan), erythromycin, and antiemetics was unsuccessful in controlling the symptoms.

Gastric Peroral Endoscopic Myotomy: A Specific Learning Curve.

Gastric peroral endoscopic pyloromyotomy (G-POEM) is a novel option for patients with gastroparesis. It involves submucosal tunneling across the pylorus, followed by pyloromyotomy, and subsequent closure of the endoscopic tunnel. The aim of this study was to determine the learning curve for G-POEM. Consecutive patients undergoing G-POEM by a single operator were included from a prospective registry over 2 years. Demographics, procedure info, postprocedure follow-up data, and adverse events were collected. Nonlinear regression and cumulative sum control chart analyses were conducted for the learning curve. Clinical outcomes were improvement in Gastroparesis Cardinal Symptom Index score and gastric emptying scintigraphy. Thirty-six patients were included (16.7% M, mean age 46 y). The majority had idiopathic gastroparesis (n=16, 44%), with the remaining having diabetes (n=5, 17%), postsurgical (n=10, 28%), or other (n=4, 11%). Technical success was achieved in 35 of 36 (97%). There was a significant reduction in the total Gastroparesis Cardinal Symptom Index score (2.09 units, P<0.00001) and a significant reduction in postoperative gastric emptying scintigraphy (82.44 mins, P<0.00001). Mean follow-up was 15 months (SD, 1.05). Median procedure time was 60.5 minutes (range, 35 to 136). Cumulative sum control chart shows 60-minute procedure was achieved at the 18th procedure. Procedure durations further reduced with consequent procedures with the last 3 being 45 minutes, thus demonstrating continued improvement with ongoing experience (nonlinear regression P<0.0001). Endoscopists experienced in G-POEM are expected to achieve a reduction in procedure time over successive cases, with efficiency reached at 60.5 minutes and a learning rate of 18 cases with continuing improvement.

Gastric peroral endoscopic pyloromyotomy for decompensated gastroparesis: comprehensive motility analysis in relation to treatment outcomes.

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.

S0951 Effect of Opiate Usage on Patient Outcomes After Gastric Per-Oral Endoscopic Pyloromyotomy (GPOEM) for Refractory Gastroparesis

INTRODUCTION: Chronic opioid use is prevalent in patients with gastroparesis and has been associated with more severe gastrointestinal symptoms and increased healthcare utilization. GPOEM has gained recognition as an effective endoscopic therapy for treatment of refractory gastroparesis. Currently there is limited knowledge of the effect of opiate use in patients undergoing GPOEM. METHODS: We performed a single-center retrospective study of patients who underwent GPOEM for refractory gastroparesis. Patients were stratified into two groups: 1) patients on chronic opiates prior to or after GPOEM and 2) patients who were not on chronic opiates prior to or after GPOEM. Primary outcomes included gastric emptying study results pre- and post-GPOEM and symptom response pre- and post-GPOEM as measured by the Gastroparesis Cardinal Symptom Index (GCSI), a validated nine-item questionnaire with 3 subscores that rate symptom severity from absent (0) to severe (5). Univariate statistical analysis was performed using t-test (SAS, version 9.4). RESULTS: 22 patients underwent GPOEM from 2017 to 2019. Nine (41%) patients were prescribed chronic opiates both prior to and after GPOEM, while 13 (59%) patients did not have chronic opiate prescriptions before and after GPOEM. The etiology of gastroparesis was predominantly post-surgical, accounting for 7 (78%) patients on opiates and 8 (62%) of patients without opiates. Mean follow-up time for all patients after GPOEM was 8.21 ± 4.6 months. Opiate users had higher baseline and post-GPOEM four-hour residuals on GES compared to patients without opiate use (baseline: 59.3% vs 43%, P = 0.18; post-GPOEM: 40.3% vs 19.7%, P = 0.27). Mean total GCSI prior to GPOEM was not significantly different between opiate and non-opiate users (3.24 vs 3.01, P = 0.63). Non-opiate users had significantly lower mean total GCSI after GPOEM compared to patients on opiates (1.32 vs 2.32, P < 0.05), as well as significantly greater overall improvement in GCSI. (56% vs 17%, P < 0.05). CONCLUSION: Non-opiate users appear to respond more favorably to GPOEM as characterized by significantly greater improvements in GCSI scores, and significantly lower overall GCSI scores following this intervention. Multidisciplinary approaches incorporating opioid weaning protocols prior to GPOEM may improve symptom-based outcomes subsequent to this procedure.Table 1.: Clinical Characteristics of Patients with and without Opiate Use before and after GPOEMFigure 1

Peroral endoscopic pyloromyotomy for gastroparesis: a systematic review and meta-analysis.

Background and aim Gastric peroral endoscopic pyloromyotomy (G-POEM) is a new therapeutic option for refractory gastroparesis (GP). A systematic review and meta-analysis was conducted to assess the effectiveness of G-POEM in refractory GP. For the quality of evidence, we used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. Methods We performed a literature search using MEDLINE, Embase, Cochrane library, LILACS and the Science citation index for studies related to G-POEM from the inception of its technique through January 2019. We selected studies that analyzed the gastroparesis cardinal symptom index (GCSI) and 4-hour solid-phase gastric emptying scintigraphy (GES) before and after the procedure to verify the efficacy of G-POEM, the main outcome measured. An analysis was performed using RevMan 5.3. Results Ten studies comprising 281 patients were included in this systematic review. The pooled mean difference in GCSI following the procedure was 1.76 (95 % CI: [1.43, 2.08], I 2 = 72 %). We also performed GCSI subgroup analysis by follow-up duration that showed a pooled mean difference of 1.84 (95 % CI: [1.57, 2.12], I 2 = 71 %). The pooled mean difference in GES after the procedure was 26.28 (95 % CI: [19.74, 32.83], I 2 = 87 %), corresponding to a significant drop in percentage values of the gastric retention 4-hour scintigraphy. Conclusion This meta-analysis demonstrates that G-POEM is effective and shows promising outcomes in the clinical response and gastric emptying scintigraphy for gastroparesis. Therefore, it should be considered in the management of refractory gastroparesis.

Sa1278 THIRD SPACE ENDOSCOPY AFTER FORMAL ENDOSCOPY ADVANCED FELLOWSHIP TRAINING IN THE US: IS IT TIME FOR ESTABLISHED TRAINING?

Third space endoscopy includes peroral endoscopic myotomy (POEM) and gastric peroral endoscopic pyloromyotomy (GPOEM). The majority of advanced endoscopy fellowships offer training focused on ERCP and EUS. Very few advanced endoscopy fellowships offer comprehensive training in third space endoscopy in addition to ERCP and EUS given the risk associated with these procedures and the limited US expertise. Multiple studies have reported the learning curve without formal training, which in general suggest procedure certain procedure times, adverse events, clinical and technical failure. We examine the single academic center initial experience following formal third space endoscopy training. We analyzed the number of cases of third space endoscopy cases performed in one-year training and calculated the learning curve. Then we followed up the data of the procedure that was performed by the same formal trainee after practicing independently in a tertiary referral center. Video recording of all procedure was available for review by expert attendings. The trainee performed 89 POEM and GPOEM during the one-year training program under the direct supervision of an expert attending. Step by step training was programed: endoscopic tunneling and closure was followed shortly by endoscopic myotomy. The limited endoscopic incision was the final learning step. Attending-level competency was achieved after 50 procedures. In initial academic practice, 20 procedures (15 POEM, 5 GPOEM) were performed. The average procedure time for POEM and GPOEM was 40 ± 14 minutes. Average pre-procedure Eckardt score of 8 decreased to 1 following poem. Technical and short term clinical success was achieved in all cases. There were no adverse events. An average of 3 endoclips were used to close the POEM incision. Post-procedure hospital stay was one day for 18 patients and 2 days for two patients. Our initial results suggest that formal training in third space endoscopy yields excellent outcomes in the transition to academic practice, with an estimated 50 cases of direct expert supervision needed to achieve competency in these procedures. This experience may be helpful in the design of training and certification programs.

Tu1547 ENDOSCOPIC CLIPS VERSUS ENDOSCOPIC SUTURE FOR MUCOSAL CLOSURE AFTER PER ORAL ENDOSCOPIC PYLOROMYOTOMY - A PROSPECTIVE STUDY

Gastric per-oral endoscopic pyloromyotomy (GPOEM) is an emerging method for treatment of gastroparesis. Safe mucosal closure is necessary to avoid adverse events. The aim of this study was to compare the effectivity of two closure methods: clips and endoscopic suturing (ES) in patients undergoing GPOEM. A single center, prospective study (NCT:03679104). All patients, who underwent GPOEM and agreed to participate were enrolled.The closure method was assigned at the discretion of an endoscopist (one endoscopist performed all procedures) prior to the procedure. The main outcome was the proportion of subjects with successful closure. Unsuccessful closure was defined as a need for a rescue method, or a need for an additional intervention. Secondary outcomes were easiness of closure measured by a Visual Analogue Scale (scored by endoscopist and nurse) and closure time. A total of 25 patients [M:F/11:14; mean age, range: 49.2 (26–74)] have been included; 15 received ES and 10 clips (mean 6; range 5–19). All patients with ES had successful closure. One patient with clips needed a rescue method (KING closure with endoloop) and another patient needed additional clipping because of a leak on POD1. The remaining 8 patients (80%) had a successful closure with clips. Closure with clips was quicker (mean closure time 10.3 min (range 4–15) vs 14 (5–20); p=0.048). Endoscopist tended to assess closure with ES easier compared to clips (mean visual analogue scale for ES 7.4 (3–10) vs. 6.4 (3–10) for clips; p=0.25). A nurse assessed easines of both closure methods as comparable (p=0.68). Endoscopic suturing system may be more reliable than clipping for mucosal closure in patients undergoing G-POEM. Besides clips, centers performing G-POEM should have an alternative (rescue) closure method. (Supported by a grant from the Czech Ministry of Health 17-28797A).

Long-term Outcome of Gastric Per-Oral Endoscopic Pyloromyotomy in Treatment of Gastroparesis

Gastric per oral endoscopic pyloromyotomy (GPOEM) is a promising treatment for gastroparesis. There are few data on the long-term outcomes of this procedure. We investigated long-term outcomes of GPOEM treatment of patients with refractory gastroparesis. We conducted a retrospective case-series study of all patients who underwent GPOEM for refractory gastroparesis at a single center (n = 97), from June 2015 through March 2019; 90 patients had more than 3 months follow-up data and were included in our final analysis. We collected data on gastroparesis cardinal symptom index (GCSI) scores (measurements of postprandial fullness or early satiety, nausea and vomiting, and bloating) and SF-36 questionnaire scores (measures quality of life). The primary outcome was clinical response to GPOEM, defined as a decrease of at least 1 point in the average total GCSI score with more than a 25% decrease in at least 2 subscales of cardinal symptoms. Recurrence was defined as a return to baseline GCSI or GCSI scores of 3 or more for at least 2 months after an initial complete response. The secondary outcome was the factors that predict GPOEM failure (no response or gastroparesis recurrence within 6 months). At initial follow-up (3 to 6 months after GPOEM), 73 patients (81.1%) had a clinical response and significant increases in SF-36 questionnaire scores (indicating increased quality of life) whereas 17 patients (18.9%) had no response. Six months after GPOEM, 7.1% had recurrence. At 12 months, 8.3% of patients remaining in the study had recurrence. At 24 months, 4.8% of patients remaining in the study had a recurrence. At 36 months, 14.3% of patients remaining in the study had recurrence. For patients who experienced an initial clinical response, the rate of loss of that response per year was 12.9%. In the univariate and multivariate regression analysis, a longer duration of gastroparesis reduced the odds of response to GPOEM (odds ratio [OR], 0.092; 95% CI, 1.04-1.3; P = .001). On multivariate logistic regression, patients with high BMIs had increased odds of GPOEM failure (OR, 1.097; 95% CI, 1.022-1.176; P = .010) and patients receiving psychiatric medications had a higher risk of GPOEM failure (OR, 1.33; 95% CI, 0.110-1.008; P = .052). In retrospective analysis of 90 patients who underwent GPOEM for refractory gastroparesis, 81.1% had a clinical response at initial follow-up of their procedure. 1 year after GPOEM, 69.1% of all patients had a clinical response and 85.2% of initial responders maintained a clinical response. Patients maintained a clinical response and improved quality of life for as long as 3 years after the procedure. High BMI and long duration gastroparesis were associated with failure of GPOEM.

Correction: Gastric peroral endoscopic pyloromyotomy versus gastric electrical stimulation in the treatment of refractory gastroparesis: a propensity score-matched analysis of long term outcomes.

Correction: Gastric peroral endoscopic pyloromyotomy versus gastric electrical stimulation in the treatment of refractory gastroparesis: a propensity score-matched analysis of long term outcomes.

Outcomes of Gastric Per-Oral Endoscopic Pyloromyotomy for Severe Gastroparesis in a Lung Transplant Patient Population

Gastroparesis is a common and potentially devastating complication of lung transplantation. Initial results of Gastric Per-oral Endoscopic Pyloromyotomy (G-POEM) for the treatment of gastroparesis are encouraging but it's use in lung transplant is unknown. Retrospective cohort analysis of consecutive patients treated with G-POEM for medically refractory gastroparesis secondary to lung transplantation. Clinical, demographic, procedural and post procedural data was collected. 11 patient underwent G-POEM procedure. Technical and clinical success was noted in all 11 patients. Statistically significant decreases in gastroparesis symptom scores (GCSI) were noted in all 11 patients. In patients that obtained repeat GES, 100% experienced improvements in 4 hr GES emptying. Normalization of GES (<10% retention at 4 hrs) was noted in 3/7 patients. No significant difference in FEV1 or FVC was noted post G-POEM. 1 patient experienced accidental mucosotomy and 1 patient delayed pyloric stricture. All adverse events were managed endoscopically. G-POEM is a safe and efficacious treatment for medical refractory gastroparesis secondary to lung transplantation.

Gastric peroral endoscopic pyloromyotomy versus gastric electrical stimulation in the treatment of refractory gastroparesis: a propensity score-matched analysis of long term outcomes.

BACKGROUND : Gastric peroral endoscopic pyloromyotomy (G-POEM) and gastric electrical stimulation (GES) have been reported as treatment options for refractory gastroparesis. In this study, we compared the long term clinical outcomes of G-POEM versus GES in the treatment of such patients. METHODS : We retrospectively evaluated 111 consecutive patients with refractory gastroparesis between January 2009 and August 2018. To overcome selection bias, we used propensity score matching (1:1) between G-POEM and GES treatment. The primary outcome was the duration of clinical response. RESULTS : After propensity score matching, 23 patients were included in each group. After a median follow-up of 27.7 months, G-POEM had a significantly better and longer clinical response than GES (hazard ratio [HR] for clinical recurrence 0.39, 95 % confidence interval [CI] 0.16 - 0.95; P = 0.04). The median duration of response was 25.4 months (95 %CI 8.7 - 42.0) in the GES group and was not reached in the G-POEM group. The Kaplan - Meier estimate of 24-month clinical response rate was 76.6 % with G-POEM vs. 53.7 % with GES. GES appeared to have little effect on idiopathic gastroparesis (HR for recurrence with G-POEM vs. GES 0.35, 95 %CI 0.13 - 0.95; P = 0.05). The incidence of adverse events was higher in the GES group (26.1 % vs. 4.3 %; P = 0.10). CONCLUSION : Among patients with refractory gastroparesis, clinical response was better and lasted longer with G-POEM than with GES. The positive outcomes with G-POEM are likely to derive from the superior clinical response in patients with idiopathic gastroparesis. Further studies are needed to confirm these findings.