Duration or etiology of gastroparesis and clinical response after gastric per-oral endoscopic pyloromyotomy

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Post written by Parit Mekaroonkamol, MD, Vaishali Patel, MD, MHS, and Qiang Cai, MD, PhD, from the Emory University School of Medicine, Atlanta, Georgia, and the King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok, Thailand.

Gastric per-oral endoscopic pyloromyotomy (GPOEM) is an emerging endoscopic procedure for treatment of gastroparesis. Although multiple studies have demonstrated impressive clinical response, it remains challenging to properly select those patients whom it might benefit the most. The purpose of our study was to evaluate the safety and efficacy of the procedure, and also to explore the impact of duration and etiology (diabetic vs non-diabetic) of gastroparesis on the clinical outcome as measured by the gastroparesis cardinal symptom index (GCSI).

Gastroparesis is a chronic debilitating disease with limited therapeutic options. While GPOEM has the potential to ascend to the forefront of treatment, there is currently no reliable way to predict which patients will respond to it. Therefore, it is vital to learn more regarding the prognostic factors to predict clinical response.

Our study showed that GCSI significantly improved throughout 18 months of the study period (F [2.176, 17.405]=10.152, P=0.001). While there was sustained improvement in nausea/vomiting, there was no significant improvement in bloating. Gastric scintigraphy retention was also significantly reduced by 41.7% (t=-7.90; P<0.00001). These findings correlated with those from prior studies that suggest a greater response to pylorus-directed intervention in patients with predominantly nausea/vomiting symptoms. Multivariate linear regression modeling revealed a significant correlation between the duration of gastroparesis and GCSI improvement at 12 months (P=0.02), with a longer duration being associated with a poorer long-term response. The etiology of gastroparesis (diabetic vs non-diabetic) was not associated with clinical improvement (P=0.16). The adverse event rate was 7.5% and included one capnoperitoneum, one peri-procedure COPD exacerbation, and one mucosotomy closure site disruption. Based on these results, we believe that GPOEM should be offered for patients with predominantly nausea/vomiting symptoms, and with shorter duration of gastroparesis, regardless of the etiology. We also propose that the clinical criteria for undergoing GPOEM should be a GSCI of at least 2.0 and a gastric retention of greater than 20% (at 4 hours) based on the maximal responses observed in our study.

Currently, GPOEM and gastric electrical stimulation (GES) are the only minimally invasive treatments for medically refractory gastroparesis. However, GES still requires a surgical procedure for implantation and the data regarding its clinical efficacy has been conflicted. Comparative data between GPOEM and GES is needed in future studies.

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Figure 1. Gastric per-oral endoscopic pyloromyotomy procedure. A, Mucosotomy, 3-4 cm in length, performed 5-7 cm proximal to the pylorus to allow submucosal entry. B and C, Submucosal tunneling. D, Identification of pyloric ring. E, Selective circular myotomy. F, Defect closure using endoclips.

 

Read the full article online.

The information presented in Endoscopedia reflects the opinions of the authors and does not represent the position of the American Society for Gastrointestinal Endoscopy (ASGE). ASGE expressly disclaims any warranties or guarantees, expressed or implied, and is not liable for damages of any kind in connection with the material, information, or procedures set forth.

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