Treatment Of Refractory Gastroparesis Research Articles

Short-term outcomes of gastric per-oral endoscopic pyloromyotomy (G-POEM) then and now: a comparison analysis

Summary Background Gastric per-oral endoscopic pyloromyotomy (G-POEM) has been performed for 10 years in the treatment of refractory gastroparesis (Gp). Many studies from the early years of G‑POEM reported short-term outcomes with 60–80% clinical success. Notably, no recent studies have assessed short-term outcomes after a decade of experience with this procedure. In this study, we compare the short-term outcomes of our initial 16 patients undergoing G‑POEM 8 years ago with 16 of our recent patients undergoing G‑POEM. Patients and methods The initial 16 patients who underwent G‑POEM from 06/2015 to 07/2016 (group A; the first 16 G-POEM procedures QC performed) and 16 recent patients who underwent G‑POEM from 07/2021 to 01/2022 (group B; the first 16 procedures performed when QC moved to a different institution) were enrolled in the study. Patients’ demographics, clinical success, procedure time, and length of hospital stay were analyzed and compared between the two groups. All procedures were performed by a single advanced endoscopist (QC). Results Patients’ age, gender, and etiology of gastroparesis were similar between the two groups. There were no differences between the two groups in terms of short-term clinical outcomes. However, there was a significant difference in procedure time and the length of hospital stay between the two groups. There were no adverse events reported for either group A or group B. Conclusion For a single experienced advanced submucosal endoscopist, there were no differences in the short-term clinical outcomes of G‑POEM when comparing the initial timeframe of performing G‑POEM with that after 8 years of experience at the time of the study in a different institution. Notably, the procedure time and the length of hospital stay were significantly shorter after 8 years of practice.

Gastric peroral endoscopic myotomy in refractory gastroparesis: long-term outcomes and predictive score to improve patient selection

Limited data exist concerning the long-term efficiency of gastric peroral endoscopic myotomy (G-POEM) as a treatment of refractory gastroparesis. This study evaluated the 3-year results of G-POEM in patients with refractory gastroparesis. This was a prospective multicenter study of all G-POEM operations performed in 2 expert French centers for 46 patients with refractory gastroparesis with at least 3 years of follow-up. Clinical success was 65.2% at 36 months. There was significant improvement in symptom severity. Median Gastroparesis Cardinal Symptom Index decreased from 3.33 to 1.80 (P< .0001), with improvement in all subscales. We created a predictive score concerning G-POEM success (G-POEM predictive score) to which points were assigned as follows: nausea subscale<2: predictive of success, 1 point; satiety subscale >4: predictive of success, 1 point; bloating subscale >3.5: predictive of success, 1 point; percentage of gastric retention at 4 hours on scintigraphy >50%: 1 point. A threshold of 2 was identified by receiver operating characteristic curve analysis with an area under the curve of .825 that predicted clinical success with a sensitivity of 93.3% (95% confidence interval [CI], .77-.99), specificity of 56.3% (95% CI, .33-.77), positive predictive value of 80% (95% CI, .67-.93), negative predictive value of 81.8% (95% CI, .59-1.00), and accuracy of 80.4% (95% CI, .69-.92). Patients with a score≥2 were significantly more likely to be responders at 3 years than were patients with a score<2 (80% and 18%, respectively; P= .0004). The clinical success of G-POEM for refractory gastroparesis was 65.2% at 36 months. Our predictive score offers an easy tool that needs to be confirmed in other studies.

O-BN08 Quality of Life 21 Years Following Gastric Pacing/ Gastric Electrical Stimulation for Gastroparesis – A real life data

Abstract Background Gastroparesis is defined as delayed emptying of the stomach in the absence of mechanical obstruction. Gastroparesis symptoms ranging from nausea, vomiting, bloating and abdominal pain with significant impact on overall quality of life (QALY). Gastric electrical stimulation (GES) for gastroparesis has been used in clinical practice since 1998 and was initially licensed as a “humanitarian” treatment when all else had failed. In the last two decades, it has been increasingly used in the treatment of refractory gastroparesis. We have been performing GES for refractory Gastroparesis since 2000 and we present our data on symptoms, quality of life and resource utilization Methods A prospective consecutive cohort study at a single center from December 2000 to July 2021 has been conducted. Data on patient demographics (gender and age), comorbidities, aetiology, the method of surgery, pre and post hospital stay, pre and post-operative SF-36 questionnaire (QALY) and symptom score (Likert Score), adjunct intervention, feeding regimen, mortality and morbidity were collated and subjected to student t-test for parametric data, the Wilcoxon test for non-parametric data, and McNemar’s test for binomial data Results A total of 162 patients underwent GES. There were 118 females. The median age was 36.5 years (range 6-80). Ninety-two patients were Idiopathic, 63 were Diabetic and 7 Post-Surgical. Overall QALY improved from a mean of 190/500 to 415/500(p = &amp;lt;0.001) with significant improvement in nausea (p = &amp;lt;0.001), abdominal pain (p = 0.005) and bloating (p = 0.001) severity score prior and following surgery. Number of hospital admissions (median) reduced post GES insertion from six to zero per year (p = 0.002). The median length of stay was 3 days (range 1-45) and follow up was up to 129 months (6-252). There was no mortality from the procedure. Conclusions This is one of a few long-term studies looking at the outcome following GES for Gastroparesis. Our data shows that GES is a safe procedure with very little morbidity and no mortality. It improves symptoms and quality of life. It also reduces the health care utilization for these patients. The effects of GES are also very durable and hence should be considered as a mainstream treatment for patients with refractory gastroparesis.

Beyond Metoclopramide for Gastroparesis

Beyond Metoclopramide for Gastroparesis

Gastric per-oral endoscopic myotomy (G-POEM) for refractory gastroparesis: results from an international prospective trial

ObjectiveAlthough gastric per-oral endoscopic myotomy (G-POEM) is considered a promising technique for the management of refractory gastroparesis, high-quality evidence is limited. We prospectively investigated the efficacy and safety of G-POEM...

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.

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.

Clinical efficacy of gastric per-oral endoscopic myotomy (G-POEM) in the treatment of refractory gastroparesis and predictors of outcomes: a systematic review and meta-analysis using surgical pyloroplasty as a comparator group.

Gastric peroral endoscopic myotomy (G-POEM) is a novel minimally invasive technique in endosurgery. Data is limited as to its efficacy, safety, and predictive factors. We conducted this meta-analysis to evaluate the clinical outcomes of G-POEM and used the outcomes of surgical pyloroplasty as a comparator group in the treatment of refractory gastroparesis. We searched multiple databases from inception through March 2019 to identify studies that reported on G-POEM and pyloroplasty in gastroparesis. Our primary outcome was to analyze and compare the pooled rates of clinical success, in terms of Gastroparesis Cardinal Symptom Index (GCSI) score and 4-h gastric emptying study (GES) results, with G-POEM and pyloroplasty. Three hundred and thirty-two and 375 patients underwent G-POEM (11 studies) and surgical pyloroplasty (seven studies), respectively. The pooled rate of clinical success, based on the GCSI score, with G-POEM was 75.8% (95% CI 68.1-82.1, I2 = 50) and with surgical pyloroplasty was 77.3% (95% CI 66.4-85.4, I2 = 0), with no significance, p = 0.81. The pooled rate of clinical success, based on the 4-hour GES results, with G-POEM was 85.1% (95% CI 68.9-93.7, I2 = 74) and with surgical pyloroplasty was 84% (95% CI 64.4-93.8, I2 = 81), with no significance, p = 0.91. The overall adverse events were comparable. Based on meta-regression analysis, idiopathic gastroparesis, prior treatment with botulinum toxin and gastric stimulator seemed to predict clinical success with G-POEM. G-POEM demonstrates clinical success in treating refractory gastroparesis. Idiopathic gastroparesis, prior treatment with botulinum injections and gastric stimulator appear to have positive predictive effects on the 4-h GES results after G-POEM. Outcomes seem comparable to surgical pyloroplasty.

903 Clinical Efficacy of Gastric Per-Oral Endoscopic Myotomy in the Treatment of Refractory Gastroparesis and Predictors of Successful Outcomes: A Systematic Review and Meta-Analysis

INTRODUCTION: Options to treat medically refractory gastroparesis are limited. Gastric peroral endoscopic myotomy (G-POEM) is a novel minimally invasive technique in endosurgery that has shown promising results. Data is limited as to its efficacy, safety, predictive factors and its comparability to surgical pyloroplasty. The aim of our study was to synthesize and analyze the clinical outcomes of GPOEM by meta-analysis methods. METHODS: We searched multiple databases from inception through March 2019 to identify studies that reported on G-POEM and surgical pyloroplasty in gastroparesis. Our primary outcome was to analyze the pooled rates of gastroparesis cardinal symptom index (GCSI) score and 4-hr gastric emptying study (GES) results, with G-POEM. Similar outcomes with surgical pyloroplasty was used as a comparator group. RESULTS: 332 and 375 patients underwent G-POEM (11studies) and pyloroplasty (7studies), respectively. The pooled rate of clinical success, based on the GCSI score, with G-POEM was 75.8% (95% CI 68.1-82.1, I2 = 50) and with pyloroplasty was 77.3% (95% CI 66.4-85.4, I2 = 0), with no significance,P = 0.81. The pooled rate of clinical success, based on the 4-hour GES results, with GPOEM was 85.1% (95% CI 68.9-93.7, I2 = 74) and with pyloroplasty was 84% (95% CI 64.4-93.8, I2 = 81), with no significance, P = 0.91. The pooled rate of mean pre-G-POEM GCSI score was 3.4 (95% CI 3.1-3.7, I2 = 89) and post-G-POEM GCSI score was 1.8 (95% CI 1.4-2.1, I2 = 89), with statistical significance (P = 0.001). The pooled pre-G-POEM 4-hr GES was 49.9% (95% CI 41.6-58.3, I2 = 94) and post-G-POEM 4-hr GES was 20.6% (95% CI 12.3-28.8, I2 = 77), with statistical significance (P = 0.001). The pre and post pyloroplasty 4-hr GES results were 36% (95% CI 32.7-39.3, I2 = 88) and 3.9% (95% CI 2.3-5.5, I2 = 43), respectively (P = 0.001). The pre and post pyloroplasty GCSI score was not analyzed due to paucity in data. The overall adverse events were comparable (11%, 5.9-19.8, I2 = 66 vs 11.4%, 5-24, I2 = 69, P = 0.95). Based on meta-regression analysis, idiopathic-gastroparesis, prior treatment with botulinum toxin and gastric-stimulator seemed to predict clinical success with G-POEM. CONCLUSION: G-POEM demonstrates clinical success in treating refractory gastroparesis with comparable outcomes to pyloroplasty. Idiopathic gastroparesis, prior treatment with botulinum injection and gastric stimulator appear to have positive predictive effects on the 4-hr GES results after G-POEM.

Botulinum Toxin as a Treatment for Refractory Gastroparesis: a Literature Review.

Gastroparesis (GP) is a disorder of gastrointestinal motility which leads to delayed gastric emptying in the absence of mechanical obstruction. Treatment is limited as many patients are refractory to dietary modification and the use prokinetic medications carry significant adverse risks. These limitations necessitate more research into experimental therapies. The purpose of this article is to summarize the known information and guidelines on the diagnosis and management of GP and to review the latest literature on experimental treatments. Based on the current available literature, there is conflicting data regarding the efficacy of intra-pyloric botulinum injections (IPBIs) for refractory gastroparesis. There have been many open-label trials showing good clinical response, but the only two randomized controlled trials on the matter showed no objective improvement gastric emptying studies. However, both studies were likely underpowered and changes in gastric emptying may not correlate with symptom improvement. As such, these discouraging findings should not be used to exclude botox from the armamentarium of therapies for refractory GP. More large-scale, double-blinded, multicenter randomized control trials are needed to further validate the long-term efficacy and safety of IPBI, as well as gastric peroral endoscopic myotomy (G-POEM), as compared to gastric electrical stimulation (GES) or surgical intervention (i.e., laparoscopic pylorotomy) for refractory gastroparesis.

State of the art review with literature summary on gastric peroral endoscopic pyloromyotomy for gastroparesis.

Gastroparesis is a debilitating progressive disease that significantly impacts a patient's life with limited and challenging treatments available. Although the pathogenesis is multifactorial, pylorospasm is believed to have a major underlying role. Several therapeutic interventions directed to the pylorus have been developed over the last decade, including intra-pyloric injections of botulinum toxin, transpyloric stenting, and surgical pyloroplasty. All of these treatment options had limited and disappointing results. More recently, gastric peroral endoscopic myotomy (G-POEM) has been reported as a treatment for refractory gastroparesis. In this review article, we provide an overview on gastroparesis with a focus on the therapeutic interventions. In addition, we provide a literature summary and pool analysis of the clinical efficacy, scintigraphic efficacy, and safety profile of all studies that evaluated G-POEM in gastroparesis. Overall, seven studies have reported on the use of G-POEM in gastroparesis, and the pooled analysis of these studies showed a technical success of 100%, with clinical efficacy as assessed by the Gastroparesis Cardinal Symptoms Index of 81.5%, gastric emptying scintigraphy normalization in approximately 55.5% of the cases, perioperative complications in 7.6%, and intraoperative complications in 6.6%. This suggests that G-POEM is a new promising therapeutic intervention for the treatment of gastroparesis with durable effect and limited potential adverse events.

Gastric interventional endoscopy.

To review new advances in gastric interventional endoscopy. Implementation of gastric endoscopy as a therapeutic option in obesity, gastric cancer, and gastroparesis. Less invasive new gastric endoscopic procedures can potentially replace currently offered laparoscopic approaches in many fields. In this article, we will review the use of endoscopic sleeve gastroplasty as a weight loss procedure, endoscopic submucosal dissection in treatment of early gastric cancer, and gastric per-oral endoscopic myotomy in treatment of refractory gastroparesis. These procedures can increase access to bariatric weigh loss procedures, provide an organ-saving curative option for early gastric cancer, and offer a new modality to improve refractory gastroparesis.

Cost-Effective Analysis of Gastric Peroral Endoscopic Pyloromyotomy (GPOEM) in Treatment of Refractory Gastroparesis

Cost-Effective Analysis of Gastric Peroral Endoscopic Pyloromyotomy (GPOEM) in Treatment of Refractory Gastroparesis

Effect of Gastroparesis Etiology on Clinical Response to Gastric Peroral Endoscopic Pyloromyotomy (GPOEM)

Introduction: Gastroparesis is a heterogenous disorder with broad clinical spectrum. Etiology of gastroparesis was shown to influence clinical severity and response to therapy. Gastric per oral endoscopic pyloromyotomy (GPOEM) has shown an exciting success in treatment of refractory gastroparesis but its clinical impact on different subtypes of gastroparesis is currently unknown. This study aims to evaluate clinical responses of GPOEM based on etiology of gastroparesis. Methods: This retrospective cohort study was conducted in patients with refractory gastroparesis who underwent GPOEM. Symptoms and quality of life were scored using Gastroparesis Cardinal Symptom Index (GCSI) and a short-form 36 questionnaire (SF36) before and after the procedure at 1, 6, and 12-month. Gastric emptying scintigraphy (GES) was obtained at baseline and at 8 weeks. Comparative analysis of clinical outcomes was performed. Results: 12 patients with diabetic gastroparesis (DG), 12 patients with idiopathic gastroparesis (IG), and 5 patients with post-surgical gastroparesis (PG) were included. There was no statistically significant difference in baseline disease severity across all group, measured by GCSI (F=0.04; p=0.96), SF36 (F=0.24; p=0.79), and GES (F=1.48; p=0.28). DG cohort had significantly longer duration of the disease (6.7+/-3.8 years), compared to IG (t=1.92; p=0.03) and PG group (t=-2.2; p=0.01). Overall, 76.9% of patients achieved clinical response. All group had statistically significant improvement in GES, GCSI, and SF36. There was no significant difference on degree of improvement of GES (F=0.3; p=0.74), GCSI (F=0.09; p=0.91), and SF36 (F=1.14; p=0.33) at 1-month post GPOEM among 3 groups. There was no significant difference on the improvement of GCSI and SF36 between DG and IG at both 6-month (t=0.18; p=0.85 and t=-1.4; p=0.18) and 12-month post procedure (t=-0.5; p=0.6 and t=0.58; p=0.58). Subgroup analyses of clinical responses on each primary symptom of nausea, early satiety, bloating, and pain did not show any significant differences among DG, IG, and PG cohort. Conclusion: GPOEM resulted in improved GSCI and quality of life that sustained throughout a 12-month period in all subtype of gastroparesis, including DG, IG and PG, with a similar degree of improvement. Despite a greater decrease in nausea and early satiety, compared to bloating and pain, they did not reach statistical significance in subgroup analyses. Larger studies are warranted to determine factors associated with favorable outcomes.Figure: Improvement of GCSI after GPOEM in each subtype of gastroparesis;GCSI: gastroparesis cardinal symptoms index; GPOEM: gastric per oral endoscopic pyloromyotomy.Figure: Improvement of quality of life after GPOEM in each subtype of gastroparesis;SF36: Short form 36; GPOEM: gastric per oral endoscopic pyloromyotomy.Figure: Improvement of GES after GPOEM in each subtype of gastroparesis;GES: gastric emptying scintigraphy; GPOEM: gastric per oral endoscopic pyloromyotomy; DG: diabetic gastroparesis; IG: idiopathic gastroparesis; PG: post-surgical gastroparesis.

741 Gastric Per-Oral Endoscopic Myotomy for the Treatment of Refractory Gastroparesis: A Multi-Centered International Experience

Gastroparesis is a difficult to treat motility disorder with poor response to medical therapy. We present a multi-centered cases series of our experience with gastric per-oral endoscopic pyloromyotomy (G-POEM) in the treatment of refractory gastroparesis.

Gastric per-oral endoscopic myotomy with antropyloromyotomy in the treatment of refractory gastroparesis: clinical experience with follow-up and scintigraphic evaluation (with video)

Gastroparesis is a chronic, debilitating condition. We report an experience conducting gastric per-oral endoscopic pyloromyotomy (G-POEM) with objectives to assess clinical efficacy, gastric emptying evolution, and procedural adverse events. This was a clinical pilot series on 12 consecutive patients who underwent G-POEM for refractory gastroparesis in our tertiary center between February 2014 and August 2015. Patients included had severe disease as defined by elevated Gastroparesis Cardinal Symptoms Index (GCSI) score and delayed gastric emptying scintigraphy (GES). G-POEM was performed by mucosal incision upstream the pylorus followed by submucosal tunnel and antropyloromyotomy with subsequent access closure. Efficacy was assessed at 5 days, 1 month, and 3 months, based on GCSI score, and individualizing (Likert scale) the main symptoms (nausea, vomiting, abdominal pain, early satiety, and anorexia). GES was performed 2 months after the procedure. G-POEM was successfully performed in all 12 patients, yielding a technical success rate of 100%. Significant improvements in GCSI were observed: 3.5 ± .8 versus .9 ± .9 (1 month) and 1.1 ± 1.5 (3 months), respectively (P<.001), as well as the severity of main symptoms at 3 months. Clinical efficacy was 85% (10/12). GES normalized in 75% of cases, with improvement of half emptying time (222 ± 90 minutes vs 133 ± 90 minutes; P= .03) and retention at 2 hours (76% ± 20% vs 44% ± 26%; P= .009). There were no adverse events related to the procedure. We report a single-center study evaluating G-POEM for refractory gastroparesis, demonstrating its feasibility, reproducibility, and safety with promising clinical and scintigraphic efficacy.

715 Per Oral Endoscopic Pyloromyotomy After Sub-Mucosal Tunnel for the Treatment of Refractory Gastroparesis: The First European Clinical Series

715 Per Oral Endoscopic Pyloromyotomy After Sub-Mucosal Tunnel for the Treatment of Refractory Gastroparesis: The First European Clinical Series

OC-086 Gastric electrical stimulation (ges) for the treatment of refractory gastroparesis: a prospective 14-year experience in a uk centre

Introduction Gastroparesis is a debilitating disorder of gastric motility resulting in symptoms of nausea, vomiting, bloating and abdominal pain. In non-responders to medical treatment, Gastric Electrical Stimulation (GES) can improve symptoms leading to an improved quality of life. We present our 14-year experience with GES insertion in gastroparetic patients resistant to medical treatment. Method Data was prospectively collected from December 2000 to January 2015 in a local database. Information on patient demographics, pre and post GES insertion scores for nausea, vomiting, satiety, bloating and abdominal pain were collated. Factors such as aetiology of gastroparesis, comorbidities and feeding requirements were also recorded. Data on surgical intervention, complications and number of hospital admissions pre and post GES insertion were also included. Quality of life was assessed by SF-36 questionnaires. Results A total of 104 patients underwent GES insertion (Female 76, Male 28). The median length of stay was seven days (range 1–45 days) and follow up was 42.5 months (6–168 months). There were significant improvements in nausea severity score (p = Conclusion GES improves patient symptoms and quality of life. It reduces health care utilisation by avoiding long-term hospital stays and repeated admissions with a reduction in assisted feeding. The current study shows GES is a safe and an effective procedure in the treatment of refractory gastroparesis. To the best of our knowledge, our presented series is the longest consecutive study in Europe and UK alike. Disclosure of interest None Declared.

Gastroduodenal motility

Abnormalities of gastroduodenal motility are considered key players in the pathogenesis of upper gastrointestinal symptoms in disorders such as functional dyspepsia and gastroparesis. Abnormalities of sensory control are considered another important factor that contributes to symptom generation. This review summarizes recent progress in our understanding of gastroduodenal motility and sensitivity in health and in disease. Although gastric and small intestinal motility remain an important focus of research, including the application of the SmartPill (SmartPill Corp., Buffalo, New York, USA) wireless motility monitoring capsule, duodenal sensitivity and low-grade duodenal inflammation are new areas of interest in the pathogenesis of functional dyspepsia. A number of genetic polymorphisms associated with functional dyspepsia are being investigated, but large-scale studies are still lacking. Central processing of visceral stimuli, and its role in the pathogenesis of functional dyspepsia, is another important emerging topic. Therapeutic studies have reported on novel pharmacological approaches in functional dyspepsia and gastroparesis, as well as gastric electrical stimulation in the treatment of refractory gastroparesis. There is gradual progress in our understanding of the pathogenesis of gastroduodenal symptoms. Areas of recent advances including the recognition of low-grade duodenal inflammation, the role of central nervous system processing in visceral hypersensitivity and the exploration of novel pharmacotherapeutic approaches.

Treatment of Refractory Gastroparesis: Gastric and Jejunal Tubes, Botox, Gastric Electrical Stimulation, and Surgery

Refractory gastroparesis is a challenging disorder for gastroenterologists, internists, surgeons, and all health care professionals involved in the care of these patients. It should be managed by a stepwise algorithm beginning with dietary modifications, then prokinetic and antiemetic medications, measures to control pain and address psychological issues, and endoscopic or surgical options in selected patients, including placement of feeding jejunostomy tubes.