Endoscopic Pyloromyotomy for Refractory Gastroparesis (GREG)

A Randomized, Sham and Cross-Over-Controlled Trial of Per-oral Endoscopic Pyloromyotomy (G-POEM) in Patients With Refractory Gastroparesis

Gastroparesis is a disorder triggered by numerous causes and it is defined by symptoms and with an objective evidence of delayed gastric emptying in the absence of obstruction.

Effective treatment for gastroparesis is challenging especially in patients with severe symptoms. In refractory gastroparesis, endoscopic or surgical treatments may therefore be considered. Endoscopic treatments include intrapyloric injection of botulinum toxin and transpyloric insertion of a metallic stent. Surgical options involve implantation of a gastric "pacemaker" (gastric stimulation), pyloroplasty and subtotal gastrectomy.

Recently, a new endoscopic technique, gastric endoscopic per oral pyloromyotomy (G-POEM) has been introduced with promising preliminary results.

The aim of this prospective, sham-controlled, cross-over study (cross-over for patients randomized to the sham arm) is to compare short and long-term efficacy and safety of G-POEM in patients with refractory gastroparesis. Symptoms and objective parameters of gastric emptying will be the main outcome criteria. The reason of using a sham protocol is to control for the potential confounders (therapeutic effects of touch and belief, which are components of the placebo effect).

Study Overview

• Status: Completed
• Conditions: Gastroparesis
• Intervention / Treatment: Procedure: Esophago-gastro-duodenoscopy; Procedure: Gastric endoscopic peroral pyloromyotomy

Detailed Description

Gastroparesis is a disorder triggered by numerous causes and it is defined by symptoms and with an objective evidence of delayed gastric emptying in the absence of obstruction (albeit pyloric spasms may play a role in a subset of patients). Gastroparesis may be a consequence of medication, surgery or diabetes but in approximately one third of patients, the cause remains unknown and the patients are diagnosed with idiopathic gastroparesis. Effective treatment for gastroparesis is challenging especially in patients with severe symptoms. The efficacy of prokinetics is dubious since they have not proven real clinical efficacy in placebo controlled trials. In refractory gastroparesis, endoscopic or surgical treatments may therefore be considered. Endoscopic treatments include intrapyloric injection of botulinum toxin and transpyloric insertion of a metallic stent. Surgical options involve implantation of a gastric "pacemaker" (gastric stimulation), pyloroplasty and subtotal gastrectomy. The partial effectiveness of botulinum toxin injection, stents and pyloroplasty suggests that disruption of the pyloric muscle may lead to a decreased intrapyloric tone and consequently to a symptomatic improvement in some patients with refractory gastroparesis.

Recently, a new endoscopic technique, gastric endoscopic per oral pyloromyotomy (G-POEM) has been introduced with promising preliminary results. Uncontrolled studies with so far limited number of patients have demonstrated a significant symptomatic improvement in approximately 70% of patients and improved or normalized of gastric emptying in more than a half of patients after G-POEM. A prospective uncontrolled study suggested that patients with idiopathic or post-surgical gastroparesis experiences higher success rate after G-POEM (70-80%) compared to patients with diabetic gastroparesis (50%).

G-POEM is, in principle, adaptation of POEM (per-oral endoscopic myotomy) in the stomach. POEM is now considered a standard treatment for esophageal achalasia and it has been shown to be safe and effective. In contrast to achalasia, pathophysiology of pyloric function in patients with gastroparesis is less understood and the explanation of how and why G-POEM should work is some-how hypothetical. For example, presumed pylorospasm has not been demonstrated as the predictive factor for treatment success of G-POEM yet. Refractory gastroparesis is often accompanied by psychological or even psychiatric disturbances and hence a placebo" effect of G-POEM cannot be ruled out. Therefore, the real clinical efficacy of G-POEM can only be demonstrated in a clinical randomized sham-controlled trial.

To assess the severity of gastroparesis-related symptoms, the Gastroparesis Cardinal Symptom Index (GCSI) has been developed for this item. The GCSI is part of a larger questionnaire PAGI-SYM (Patient Assessment of Upper Gastrointestinal Symptom severity index) established for assessment of patient-reported symptoms in gastroparesis (dyspepsia and gastroesophageal reflux). PAGI-SYM as well as GCSI subscale scores varied significantly by global disease severity, with higher (worse) scores observed in those subjects who rated their gastroparesis as moderate to severe.

The aim of this prospective, sham-controlled, cross-over study (cross-over for patients randomized to the sham arm) is to compare short and long-term efficacy and safety of G-POEM in patients with refractory gastroparesis. Symptoms and objective parameters of gastric emptying will be the main outcome criteria. The reason of using a sham protocol is to control for the potential confounders (therapeutic effects of touch and belief, which are components of the placebo effect).

Investigators plan to randomize 86 patients (43 in the active arm, ratio 1:1 active vs. sham). Sample size is calculated based on expected therapeutic success of G-POEM in 50% of patients vs. 20% in the sham group; significance level 0,05; study power 0,8; beta error 0,2; adjustment for 15% expected drop out.

Patients will be randomised in blocks of 6, stratified according to the etiologies: (idiopathic, diabetic, and post-surgical; patients after esophagectomy with gastric pull-through will not be included). Control visits will be scheduled at 3, 6, 12, 24, and 36 months. The primary outcome will be the proportion of patients with treatment success in the active group vs. sham group at 6 months after the procedure. Several secondary outcomes will also be assessed, including procedure-related parameters and safety parameters and change in Gastric Emptying Study (GET) after G-POEM vs. sham. After 6 months, patients randomized to the sham group will be offered G-POEM procedure and further followed up (cross-over part of the study) providing that they did not have a therapeutic effect of the sham procedure.

• Study Type: Interventional
• Enrollment (Actual): 42
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Belgium
  • Brussels, Belgium
    • Department of Hepatogastroenterology at Cliniques universitaires St-Luc, Brussels, Belgium
  • Leuven, Belgium
    • Translational Research in GastroIntestinal Disorders, Leuven, Belgium
• Czechia
  • Hradec Králové, Czechia, 50005
    • University Hospital in Hradec Kralove
  • Prague
    • Prague 4, Prague, Czechia, 14021
      • Institute for Clinical and Experimental Medicine
• Denmark
  • Aarhus, Denmark
    • The Department of Surgical Gastroenterology L, Denmark
• Germany
  • Augsburg, Germany, 86156
    • III. Medizinische Klinik, Medical Center/Klinikum Augsburg, Germany
  • Hamburg- Eppendorf, Germany, 20246
    • University Medical Center Hamburg- Eppendorf | UKE Department for Interdisciplinary Endoscopy, Germany
• Netherlands
  • Amsterdam, Netherlands
    • Department of Gastroenterology and Hepatology, Amsterdam, The Netherlands
• Romania
  • Cluj-Napoca, Romania
    • Regional Institute of Gastroenterology
• Slovakia
  • Martin, Slovakia
    • Jesenius Faculty of Medicine in Martin, Clinic of Gastroenterological Internal Medicine, Slovak Republic
  • Trnava, Slovakia
    • Department of Internal Medicine, University Hospital Trnava, Slovak Republic
• Sweden
  • Stockholm, Sweden, 17176
    • Department of Surgical Gastroenterology, Karolinska University Hospital, Stockholm, Sweden
• United Kingdom
  • London, United Kingdom, SE5 9RS
    • King's Institute of Therapeutic Endoscopy, London, UK
• United States
  • Illinois
    • Chicago, Illinois, United States, 60637
      • University of Chicago

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Refractory (> 6 months) and severe (based on a validated total GSCI = Gastroparesis Cardinal Symptom Index) gastroparesis, with confirmed gastric emptying based on a gastric emptying study: standardized protocol of scintigraphy in all patients (performed less than 4 months prior to enrolment), or confirmed by a validated gastric emptying breath test [27]. The total GSCI score must be >2.3 [28].
• Abnormal gastric emptying is defined as retention of Tc-99 m >60% at 2 h and/or ≥10% of residual activity at 4 h on a standardized sulphur colloid solid-phase gastric emptying study.
• Radiolabelled liquids emptying study will be reserved as alternative technique for patients with poor tolerance of solids during scintigraphy. Abnormal gastric emptying will represent >50% retention of radiolabelled content (e.g. In-111) at 1 hour.
• Abnormal gastric empyting breath test based on a solid normal range determination for the test used (e.g. T1/2 > 109 min)

Exclusion Criteria:

• Age less than 18 years
• No previous attempt with at least one prokinetic drug
• No previous attempt to withdraw anticholinergic agents and glucagon like peptide -1 (GLP-1) and amylin analogues* in patients treated with these substances
• Active treatment with opioids or a history of treatment with opioids within 12 months before enrolment.
• Previous gastric surgery BI or II, esophagectomy, gastric pull-through
• Previous pyloromyotomy or pyloroplasty
• Known eosinophilic gastroenteritis
• Organic pyloric (or intestinal) obstruction (fibrotic stricture, etc.)
• Severe coagulopathy
• Esophageal or gastric varices and /or portal hypertensive gastropathy
• Advanced liver cirrhosis (Child B or Child C)
• Active peptic ulcer disease
• Pregnancy or puerperium
• Malignant or pre-malignant gastric diseases (dysplasia, gastric cancer, GIST)
• Any other condition, which in the opinion of the investigator would interfere with study requirements
• Uncontrolled diabetes mellitus
• Diagnosis of rumination syndrome or "eating" disorder (mental anorexia, bulimia nervosa) **
• Severe constipation without using laxatives
• Inability to obtain informed consent

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Crossover Assignment
• Masking: Double

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Sham Comparator: Esophago-gastro-duodenoscopy; Standard endoscopic examination of the upper GI tract with flexible endoscope.	Procedure: Esophago-gastro-duodenoscopy; Standard endoscopic examination of the upper GI tract with flexible endoscope
Experimental: Gastric endoscopic peroral pyloromyotomy; Experimental per-oral endoscopic myotomy of the pyloric sphincter	Procedure: Gastric endoscopic peroral pyloromyotomy; G-POEM is, in principle, adaptation of POEM (per-oral endoscopic myotomy) in the stomach. The procedure consists of: Mucosal incision at the greater curvature 3-5 cm from the pylorus; Submucosal tunnelling; Finding pyloric sphincter; Myotomy (2-3 cm) of the pyloric muscle; Incision closure (endoclips or suture device); Other Names: G-POEM

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Main outcome is the proportion of patients with treatment success after the procedure.	Treatment success is defined as a decrease of a total Gastroparesis Cardinal Symptom Index (GCSI) symptom score at least 50% from the baseline	6 months

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Proportion of patients with treatment success in the active arm after 3 months	Treatment success is defined as a decrease of a total Gastroparesis Cardinal Symptom Index (GCSI) symptom score at least 50% from the baseline	3 months
Proportion of patients with treatment success in the active arm after 12 months	Treatment success is defined as a decrease of a total Gastroparesis Cardinal Symptom Index (GCSI) symptom score at least 50% from the baseline	12 months
Proportion of patients with treatment success in the active arm after 24 months	Treatment success is defined as a decrease of a total Gastroparesis Cardinal Symptom Index (GCSI) symptom score at least 50% from the baseline	24 months
Proportion of patients with treatment success in the active arm after 36 months	Treatment success is defined as a decrease of a total Gastroparesis Cardinal Symptom Index (GCSI) symptom score at least 50% from the baseline	36 months
Proportion of patients with treatment success in the sham group at 3M	Treatment success is defined as a decrease of a total Gastroparesis Cardinal Symptom Index (GCSI) symptom score at least 50% from the baseline	3 months
Change in Gastroparesis Cardinal Symptom Index (GCSI) before and after G-POEM at 3, 6, 12, 24 and 36M and before vs. after sham procedure at 3M and 6M;	Comparison of the change of the scores between the active and sham groups.	3, 6, 12, 24 and 36 months
Change in The Patient Assessment of Gastrointestinal Disorders Symptom Severity Index (PAGI-SYM) before and after G-POEM at 3, 6, 12, 24 and 36M and before vs. after sham procedure at 3M and 6M;	Comparison of the change of the scores between the active and sham groups.	3, 6, 12, 24 and 36 months
Proportion of crossed-over patients with treatment success after 6 moths	Treatment success is defined as a decrease of a total GSCI symptom score at least 50% from the baseline	12 months
Change in Gastroparesis Cardinal Symptom Index (GCSI) crossed-over patients after the G-POEM procedure	Comparison of the change of the scores pre and post-procedure	12 months
Change in The Patient Assessment of Gastrointestinal Disorders Symptom Severity Index (PAGI-SYM) in crossed-over patients after the G-POEM procedure	Comparison of the change of the scores pre and post-procedure	12 months
Subgroup post-hoc analyses of the treatment success and change in symptomatic scores according to etiology of gastroparesis.	Treatment success is defined as a decrease of a total GSCI symptom score at least 50%, change in GCSI and PAGY-SYM scores	3, 6, 12, 24 and 36 months
Change in gastric emptying (scintigraphy) study and/or gastric emptying breath test before and after both G-POEM and sham procedure	Comparison of the mean change of these parameters between active and sham groups.	3, 6, 12, 24 and 36 months
Procedure details	length of the procedure	1 month
Procedural adverse events	perioperative adverse events (complications)	1 month
Long term adverse events	Incidence rate of adverse events in treatment and sham groups	3, 6, 12, 24 and 36 months

Collaborators and Investigators

• Sponsor: Institute for Clinical and Experimental Medicine
• Collaborators: King's College Hospital NHS Trust; Charles University, Czech Republic; Karolinska Institutet; University of Chicago; Rigshospitalet, Denmark; KU Leuven; University of Amsterdam; Cliniques universitaires Saint-Luc- Université Catholique de Louvain; Universitätsklinikum Hamburg-Eppendorf; Pavol Jozef Safarik University; Comenius University; University Hospital Augsburg; University Hospital Trnava; University of Cluj Napoca
• Investigators: Principal Investigator: Thomas Rösch, MD, PhD, University Medical Center Hamburg- Eppendorf | UKE Department for Interdisciplinary Endoscopy, Germany; Principal Investigator: Jan Martinek, MD, PhD, Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic

Publications and helpful links

General Publications

• Martinek J, Hustak R, Mares J, Vackova Z, Spicak J, Kieslichova E, Buncova M, Pohl D, Amin S, Tack J. Endoscopic pyloromyotomy for the treatment of severe and refractory gastroparesis: a pilot, randomised, sham-controlled trial. Gut. 2022 Nov;71(11):2170-2178. doi: 10.1136/gutjnl-2022-326904. Epub 2022 Apr 25.

Study record dates

Study Major Dates

• Study Start (Actual): December 1, 2017
• Primary Completion (Actual): December 24, 2020
• Study Completion (Actual): January 26, 2021

Study Registration Dates

• First Submitted: October 27, 2017
• First Submitted That Met QC Criteria: November 22, 2017
• First Posted (Actual): November 29, 2017

Study Record Updates

• Last Update Posted (Actual): January 27, 2021
• Last Update Submitted That Met QC Criteria: January 26, 2021
• Last Verified: January 1, 2021

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Digestive System Diseases; Neurologic Manifestations; Gastrointestinal Diseases; Stomach Diseases; Paralysis; Gastroparesis
• Other Study ID Numbers: IClinicalEM2

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: Undecided

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No