Gastric per-oral endoscopic myotomy: Current status and future directions

Alexander Podboy, Joo Ha Hwang, Linda A Nguyen, Patricia Garcia, Thomas A Zikos, Afrin Kamal, George Triadafilopoulos, John O Clarke, Alexander Podboy, Joo Ha Hwang, Linda A Nguyen, Patricia Garcia, Thomas A Zikos, Afrin Kamal, George Triadafilopoulos, John O Clarke

Abstract

Gastroparesis, or symptomatic delayed gastric emptying in the absence of mechanical obstruction, is a challenging and increasingly identified syndrome. Medical options are limited and the only medication approved by the Food and Drug Administration for treatment of gastroparesis is metoclopramide, although other agents are frequently used off label. With this caveat, first-line treatments for gastroparesis include dietary modifications, antiemetics and promotility agents, although these therapies are limited by suboptimal efficacy and significant medication side effects. Treatment of patients that fail first-line treatments represents a significant therapeutic challenge. Recent advances in endoscopic techniques have led to the development of a promising novel endoscopic therapy for gastroparesis via endoscopic pyloromyotomy, also referred to as gastric per-oral endoscopic myotomy or per-oral endoscopic pyloromyotomy. The aim of this article is to review the technical aspects of the per-oral endoscopic myotomy procedure for the treatment of gastroparesis, provide an overview of the currently published literature, and outline potential next directions for the field.

Keywords: Endoscopic myotomy; Gastric emptying; Gastric per-oral endoscopic myotomy; Gastroparesis; Myotomy; Per-oral endoscopic pyloromyotomy; Peroral endoscopic myotomy.

Conflict of interest statement

Conflict-of-interest statement: No potential conflicts of interest. No financial support.

Figures

Figure 1
Figure 1
Per-oral endoscopic pyloromyotomy procedure in 5 steps. A: Initial inspection; B and C: Mucosotomy; D: Submucusal tunnel dissection with identification of pyloric ring; E: Pyloromyotomy; F: Mucosal closure.

References

    1. Wang YR, Fisher RS, Parkman HP. Gastroparesis-related hospitalizations in the United States: Trends, characteristics, and outcomes, 1995-2004. Am J Gastroenterol. 2008;103:313–322.
    1. Hirsch W, Nee J, Ballou S, Petersen T, Friedlander D, Lee HN, Cheng V, Lembo A. Emergency Department Burden of Gastroparesis in the United States, 2006 to 2013. J Clin Gastroenterol. 2019;53:109–113.
    1. Jung HK, Choung RS, Locke GR, 3rd, Schleck CD, Zinsmeister AR, Szarka LA, Mullan B, Talley NJ. The incidence, prevalence, and outcomes of patients with gastroparesis in Olmsted County, Minnesota, from 1996 to 2006. Gastroenterology. 2009;136:1225–1233.
    1. Wadhwa V, Mehta D, Jobanputra Y, Lopez R, Thota PN, Sanaka MR. Healthcare utilization and costs associated with gastroparesis. World J Gastroenterol. 2017;23:4428–4436.
    1. Park MI, Camilleri M. Gastroparesis: Clinical update. Am J Gastroenterol. 2006;101:1129–1139.
    1. Camilleri M, Parkman HP, Shafi MA, Abell TL, Gerson L American College of Gastroenterology. Clinical guideline: Management of gastroparesis. Am J Gastroenterol. 2013;108:18–37; quiz 38.
    1. Abell TL, Bernstein RK, Cutts T, Farrugia G, Forster J, Hasler WL, McCallum RW, Olden KW, Parkman HP, Parrish CR, Pasricha PJ, Prather CM, Soffer EE, Twillman R, Vinik AI. Treatment of gastroparesis: A multidisciplinary clinical review. Neurogastroenterol Motil. 2006;18:263–283.
    1. Acosta A, Camilleri M. Prokinetics in gastroparesis. Gastroenterol Clin North Am. 2015;44:97–111.
    1. Rao AS, Camilleri M. Review article: Metoclopramide and tardive dyskinesia. Aliment Pharmacol Ther. 2010;31:11–19.
    1. Mearin F, Camilleri M, Malagelada JR. Pyloric dysfunction in diabetics with recurrent nausea and vomiting. Gastroenterology. 1986;90:1919–1925.
    1. Arts J, Holvoet L, Caenepeel P, Bisschops R, Sifrim D, Verbeke K, Janssens J, Tack J. Clinical trial: A randomized-controlled crossover study of intrapyloric injection of botulinum toxin in gastroparesis. Aliment Pharmacol Ther. 2007;26:1251–1258.
    1. Friedenberg FK, Palit A, Parkman HP, Hanlon A, Nelson DB. Botulinum toxin A for the treatment of delayed gastric emptying. Am J Gastroenterol. 2008;103:416–423.
    1. Bai Y, Xu MJ, Yang X, Xu C, Gao J, Zou DW, Li ZS. A systematic review on intrapyloric botulinum toxin injection for gastroparesis. Digestion. 2010;81:27–34.
    1. Clarke JO, Sharaiha RZ, Kord Valeshabad A, Lee LA, Kalloo AN, Khashab MA. Through-the-scope transpyloric stent placement improves symptoms and gastric emptying in patients with gastroparesis. Endoscopy. 2013;45 Suppl 2 UCTN:E189–E190.
    1. Khashab MA, Besharati S, Ngamruengphong S, Kumbhari V, El Zein M, Stein EM, Tieu A, Mullin GE, Dhalla S, Nandwani MC, Singh V, Canto MI, Kalloo AN, Clarke JO. Refractory gastroparesis can be successfully managed with endoscopic transpyloric stent placement and fixation (with video) Gastrointest Endosc. 2015;82:1106–1109.
    1. Jones MP, Maganti K. A systematic review of surgical therapy for gastroparesis. Am J Gastroenterol. 2003;98:2122–2129.
    1. Hibbard ML, Dunst CM, Swanström LL. Laparoscopic and endoscopic pyloroplasty for gastroparesis results in sustained symptom improvement. J Gastrointest Surg. 2011;15:1513–1519.
    1. Ahuja NK, Clarke JO. Pyloric Therapies for Gastroparesis. Curr Treat Options Gastroenterol. 2017;15:230–240.
    1. Pasricha PJ, Hawari R, Ahmed I, Chen J, Cotton PB, Hawes RH, Kalloo AN, Kantsevoy SV, Gostout CJ. Submucosal endoscopic esophageal myotomy: A novel experimental approach for the treatment of achalasia. Endoscopy. 2007;39:761–764.
    1. Inoue H, Minami H, Kobayashi Y, Sato Y, Kaga M, Suzuki M, Satodate H, Odaka N, Itoh H, Kudo S. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy. 2010;42:265–271.
    1. Inoue H, Shiwaku H, Iwakiri K, Onimaru M, Kobayashi Y, Minami H, Sato H, Kitano S, Iwakiri R, Omura N, Murakami K, Fukami N, Fujimoto K, Tajiri H. Clinical practice guidelines for peroral endoscopic myotomy. Dig Endosc. 2018;30:563–579.
    1. Khashab MA, Familiari P, Draganov PV, Aridi HD, Cho JY, Ujiki M, Rio Tinto R, Louis H, Desai PN, Velanovich V, Albéniz E, Haji A, Marks J, Costamagna G, Devière J, Perbtani Y, Hedberg M, Estremera F, Martin Del Campo LA, Yang D, Bukhari M, Brewer O, Sanaei O, Fayad L, Agarwal A, Kumbhari V, Chen YI. Peroral endoscopic myotomy is effective and safe in non-achalasia esophageal motility disorders: An international multicenter study. Endosc Int Open. 2018;6:E1031–E1036.
    1. Kawai M, Peretta S, Burckhardt O, Dallemagne B, Marescaux J, Tanigawa N. Endoscopic pyloromyotomy: A new concept of minimally invasive surgery for pyloric stenosis. Endoscopy. 2012;44:169–173.
    1. Khashab MA, Stein E, Clarke JO, Saxena P, Kumbhari V, Chander Roland B, Kalloo AN, Stavropoulos S, Pasricha P, Inoue H. Gastric peroral endoscopic myotomy for refractory gastroparesis: First human endoscopic pyloromyotomy (with video) Gastrointest Endosc. 2013;78:764–768.
    1. Shlomovitz E, Pescarus R, Cassera MA, Sharata AM, Reavis KM, Dunst CM, Swanström LL. Early human experience with per-oral endoscopic pyloromyotomy (POP) Surg Endosc. 2015;29:543–551.
    1. Gonzalez JM, Benezech A, Vitton V, Barthet M. G-POEM with antro-pyloromyotomy for the treatment of refractory gastroparesis: Mid-term follow-up and factors predicting outcome. Aliment Pharmacol Ther. 2017;46:364–370.
    1. Kahaleh M, Gonzalez JM, Xu MM, Andalib I, Gaidhane M, Tyberg A, Saumoy M, Baptista Marchena AJ, Barthet M. Gastric peroral endoscopic myotomy for the treatment of refractory gastroparesis: A multicenter international experience. Endoscopy. 2018;50:1053–1058.
    1. Rodriguez JH, Haskins IN, Strong AT, Plescia RL, Allemang MT, Butler RS, Cline MS, El-Hayek K, Ponsky JL, Kroh MD. Per oral endoscopic pyloromyotomy for refractory gastroparesis: Initial results from a single institution. Surg Endosc. 2017;31:5381–5388.
    1. Rodriguez J, Strong AT, Haskins IN, Landreneau JP, Allemang MT, El-Hayek K, Villamere J, Tu C, Cline MS, Kroh M, Ponsky JL. Per-oral Pyloromyotomy (POP) for Medically Refractory Gastroparesis: Short Term Results From the First 100 Patients at a High Volume Center. Ann Surg. 2018;268:421–430.
    1. Malik Z, Kataria R, Modayil R, Ehrlich AC, Schey R, Parkman HP, Stavropoulos SN. Gastric Per Oral Endoscopic Myotomy (G-POEM) for the Treatment of Refractory Gastroparesis: Early Experience. Dig Dis Sci. 2018;63:2405–2412.
    1. Jacques J, Pagnon L, Hure F, Legros R, Crepin S, Fauchais AL, Palat S, Ducrotté P, Marin B, Fontaine S, Boubaddi NE, Clement MP, Sautereau D, Loustaud-Ratti V, Gourcerol G, Monteil J. Peroral endoscopic pyloromyotomy is efficacious and safe for refractory gastroparesis: Prospective trial with assessment of pyloric function. Endoscopy. 2019;51:40–49.
    1. Dacha S, Mekaroonkamol P, Li L, Shahnavaz N, Sakaria S, Keilin S, Willingham F, Christie J, Cai Q. Outcomes and quality-of-life assessment after gastric per-oral endoscopic pyloromyotomy (with video) Gastrointest Endosc. 2017;86:282–289.
    1. Mekaroonkamol P, Dacha S, Wang L, Li X, Jiang Y, Li L, Li T, Shahnavaz N, Sakaria S, LeVert FE, Keilin S, Willingham F, Christie J, Cai Q. Gastric Peroral Endoscopic Pyloromyotomy Reduces Symptoms, Increases Quality of Life, and Reduces Health Care Use For Patients With Gastroparesis. Clin Gastroenterol Hepatol. 2019;17:82–89.
    1. Khashab MA, Ngamruengphong S, Carr-Locke D, Bapaye A, Benias PC, Serouya S, Dorwat S, Chaves DM, Artifon E, de Moura EG, Kumbhari V, Chavez YH, Bukhari M, Hajiyeva G, Ismail A, Chen YI, Chung H. Gastric per-oral endoscopic myotomy for refractory gastroparesis: Results from the first multicenter study on endoscopic pyloromyotomy (with video) Gastrointest Endosc. 2017;85:123–128.
    1. Gourcerol G, Tissier F, Melchior C, Touchais JY, Huet E, Prevost G, Leroi AM, Ducrotte P. Impaired fasting pyloric compliance in gastroparesis and the therapeutic response to pyloric dilatation. Aliment Pharmacol Ther. 2015;41:360–367.
    1. Malik Z, Sankineni A, Parkman HP. Assessing pyloric sphincter pathophysiology using EndoFLIP in patients with gastroparesis. Neurogastroenterol Motil. 2015;27:524–531.
    1. Snape WJ, Lin MS, Agarwal N, Shaw RE. Evaluation of the pylorus with concurrent intraluminal pressure and EndoFLIP in patients with nausea and vomiting. Neurogastroenterol Motil. 2016;28:758–764.
    1. Wellington J, Scott B, Kundu S, Stuart P, Koch KL. Effect of endoscopic pyloric therapies for patients with nausea and vomiting and functional obstructive gastroparesis. Auton Neurosci. 2017;202:56–61.
    1. Grover M, Bernard CE, Pasricha PJ, Lurken MS, Faussone-Pellegrini MS, Smyrk TC, Parkman HP, Abell TL, Snape WJ, Hasler WL, McCallum RW, Nguyen L, Koch KL, Calles J, Lee L, Tonascia J, Ünalp-Arida A, Hamilton FA, Farrugia G NIDDK Gastroparesis Clinical Research Consortium (GpCRC) Clinical-histological associations in gastroparesis: Results from the Gastroparesis Clinical Research Consortium. Neurogastroenterol Motil. 2012;24:531–539, e249.
    1. Farrugia G. Histologic changes in diabetic gastroparesis. Gastroenterol Clin North Am. 2015;44:31–38.
    1. Cipriani G, Gibbons SJ, Miller KE, Yang DS, Terhaar ML, Eisenman ST, Ördög T, Linden DR, Gajdos GB, Szurszewski JH, Farrugia G. Change in Populations of Macrophages Promotes Development of Delayed Gastric Emptying in Mice. Gastroenterology. 2018;154:2122–2136.e12.
    1. Moraveji S, Bashashati M, Elhanafi S, Sunny J, Sarosiek I, Davis B, Torabi A, McCallum RW. Depleted interstitial cells of Cajal and fibrosis in the pylorus: Novel features of gastroparesis. Neurogastroenterol Motil. 2016;28:1048–1054.
    1. Camilleri M, McCallum RW, Tack J, Spence SC, Gottesdiener K, Fiedorek FT. Efficacy and Safety of Relamorelin in Diabetics With Symptoms of Gastroparesis: A Randomized, Placebo-Controlled Study. Gastroenterology. 2017;153:1240–1250.e2.
    1. Liu Z, Zhang X, Zhang W, Zhang Y, Chen W, Qin W, Hu J, Cai M, Zhou P, Li Q. Comprehensive Evaluation of the Learning Curve for Peroral Endoscopic Myotomy. Clin Gastroenterol Hepatol. 2018;16:1420–1426.e2.
    1. Rao SS, Vemuri S, Harris B, Schulze K. Fundic balloon distension stimulates antral and duodenal motility in man. Dig Dis Sci. 2002;47:1015–1019.

Source: PubMed

Sponsorzy i współpracownicy

Warunki medyczne

Interwencje lekowe

3
Subskrybuj