Gastric peroral endoscopic pyloromyotomy for refractory gastroparesis: a systematic review of early outcomes with pooled analysis

Spadaccini, Marco; Maselli, Roberta; Chandrasekar, Viveksandeep Thoguluva; Anderloni, Andrea; Carrara, Sandro; Galtieri, Piera Alessia; Leo, Milena Di; Fugazza, Alessandro; Pellegatta, Gaia; Colombo, Matteo; Palma, Rossella; Hassan, Cesare; Sethi, Amrita; Khashab, Mouen A.; Sharma, Prateek; Repici, Alessandro

doi:10.1016/j.gie.2019.11.039

Cited by 60 publications

(51 citation statements)

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“…[2][3][4][5][6] Gastric per-oral endoscopic myotomy (G-POEM) has been described in recent case series and systemic reviews for gastroparesis therapy. [7][8][9][10] Impedance planimetry measured by the Functional Lumen Imaging Probe (EndoFLIP) can quantify several pyloric motor parameters. EndoFLIP abnormalities in gastroparesis include reduced pyloric distensibility and diameter and increased pressure.…”

Section: Introductionmentioning

confidence: 99%

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Impact of gastric per‐oral endoscopic myotomy on static and dynamic pyloric function in gastroparesis patients

Watts

Baker

Lee

et al. 2020

Neurogastroenterology Motil

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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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Section: Introductionmentioning

confidence: 99%

“…Pyloroplasties have been performed for years and pyloric botulinum toxin injections have been employed for two decades to improve gastric emptying in affected patients 2‐6 . Gastric per‐oral endoscopic myotomy (G‐POEM) has been described in recent case series and systemic reviews for gastroparesis therapy 7‐10 …”

Section: Introductionmentioning

confidence: 99%

Impact of gastric per‐oral endoscopic myotomy on static and dynamic pyloric function in gastroparesis patients

Watts

Baker

Lee

et al. 2020

Neurogastroenterology Motil

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“…We read with interest the recent article by Repici et al 1 in which the authors discuss the challenges of endoscopy in the time of the COVID-19 pandemic and suggest measures to minimize the risk of transmission in endoscopy units. We would appreciate having the authors' insight on some of the aspects that will be discussed below.…”

Section: Covid-19 Pandemic: the Long And Difficult Way Back To Workmentioning

confidence: 99%

“…It is now recognized that endoscopic procedures in COVID-19 patients are highly infecting to all involved healthcare personnel. 1,2…”

Section: Covid-19 Pandemic: the Long And Difficult Way Back To Workmentioning

confidence: 99%

What is the true effect of gastric peroral endoscopic pyloromyotomy for refractory gastroparesis?

2020

Gastrointestinal Endoscopy

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We read with interest the article by Spadaccini et al 1 evaluating gastric peroral endoscopic pyloromyotomy (G-POEM) for refractory gastroparesis. The authors found that G-POEM for refractory gastroparesis was effective and safe. Because their findings are important to current practice, several questions deserve attention. First, according to the authors' inclusion and exclusion criteria, 2 important articles, which included 73 patients, were not included. 2,3 Because there are relatively few cases of G-POEM for refractory gastroparesis, studies on G-POEM for refractory gastroparesis should be searched as comprehensively as possible. Second, the authors used "significant symptomatic improvement" as an assessment measurement; however, the definition of "significant symptomatic improvement" was quite different across the included studies. In other words, it was a subjective judgment that might have caused significant heterogeneity and may not be an ideal measurement to evaluate the effectiveness of G-POEM. Third, the Gastroparesis Cardinal Symptom Index (GCSI) was also used, but the author overlooked that dynamic change occurred in the GCSI in the follow-up. For instance, the GCSI in the report by Gonzalez et al 4 was 3.3 before the procedure, 0.95 at 1 to 3 months postoperatively, 1.0 at 6 months postoperatively, and 1.1 at 12 months postoperatively. The authors chose only 0.95 to calculate the pooled result, which might not have reflected the true effectiveness of G-POEM. Moreover, the author did not report the heterogeneity of the pooled GCSI. According to our results, the heterogeneity is very significant across the included studies, which means that the GCSI was also not an ideal assessment measurement owing to subjective attribution. In addition, we should pay attention to relapse after G-POEM. Last, all of the included studies were single-arm studies, and no comparison was made, so randomized controlled trials are still needed to compare the G-POEM with other approaches in the future.

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“…In recent years, several groups have reported promising data on G-POEM in terms of safety and efficacy outcomes in the short-and midterm [4][5][6][7][8][9][10][11][12][13]. In a recent pooled analysis of 10 studies and 292 patients with a mean follow-up of 7.8 months, a significant symptomatic improvement was achieved after 84 % of G-POEM procedures [14]. In our tertiary referral center, G-POEM is available for patients with decompensated GP (grade 3) who have followed the different treatment steps.…”

Section: Introductionmentioning

confidence: 99%

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

et al. 2021

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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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Gastric peroral endoscopic pyloromyotomy for refractory gastroparesis: a systematic review of early outcomes with pooled analysis

Abstract: Gastric peroral endoscopic pyloromyotomy for refractory gastroparesis: a systematic review of early outcomes with pooled analysis,

Cited by 60 publications

References 34 publications

Impact of gastric per‐oral endoscopic myotomy on static and dynamic pyloric function in gastroparesis patients

Impact of gastric per‐oral endoscopic myotomy on static and dynamic pyloric function in gastroparesis patients

What is the true effect of gastric peroral endoscopic pyloromyotomy for refractory gastroparesis?

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

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