Endoscopic Botulinum Toxin for Gastroparesis: Results of a Retrospective Series

Abstract

Beneficial effects of pyloric botulinum toxin injection have been described in a subgroup of gastroparesis patients. Our aim is to evaluate whether clinical, manometric and/or scintigraphic parameters are able to predict treatment outcome. Forty patients (67% female, age 49 (36–56) years) with decompensated gastroparesis treated with botulinum toxin were included in this retrospective analysis. Objective parameters were high-resolution antroduodenal manometry, gastric emptying rate (scintigraphy), and weight change. Subjective treatment outcome was assessed with a Global Physician Assessment Scale. Binary logistic regression analysis was performed to identify predictors for treatment outcome. Fourteen patients (35%) were symptom-responders, and 65% of patients were short-term weight-responders. For both subjective and objective treatment outcome, no differences were found in manometric and scintigraphic variables between responders and non-responders. Neither clinical nor manometric or scintigraphic variables could predict subjective and objective treatment outcome. In conclusion, symptom improvement is achieved in a subgroup of gastroparesis patients treated with endoscopic pyloric botulinum toxin. Although the majority of patients were able to maintain their baseline weight at short-term follow-up, a substantial group of patients needed nutritional interventions on long-term follow-up. However, none of the demographic, clinical, scintigraphic, or antroduodenal manometry variables were able to predict either subjective or objective treatment outcome.

Intrapyloric Botulinum Toxin Injection for Refractory Nausea and Vomiting in Pediatric Patients

“…Prior to our work, one study with adult patients utilized ADM to illustrate that increased symptoms of gastroparesis may be modulated by increased pyloric tonic/phasic activity and PPAHM (41). Another study in adults assessed manometric findings as related to symptomatic outcomes following IPBI, finding that manometry was poorly predictive of IPBI response (40), congruent with our findings. Only one large pediatric study has assessed ADM as related to IPBI outcomes, finding that 72% of patients undergoing ADM for gastroparesis had PPAHM (13).…”

“…ADM interpretation included antral contraction amplitude, presence of fasting phase III migrating motor complexes (MMCs), and postprandial antral hypomotility (PPAHM). Isolation of purely pyloric waveforms on ADM is difficult owing to a short distance of active muscular activity, movement of the ADM catheter during recording, and difficulty identifying the pylorus among other gastric or small bowel activity (38)(39)(40). Acknowledging these difficulties, the distal most peak antral amplitudes (most proximal to the pylorus) were selected as a surrogate for pyloric relaxation.…”

Gastroparesis: A Multidisciplinary Approach to Management

“…These interventions have promising outcomes and will likely serve as the basis for further research. Botulinum toxin A inhibits acetylcholine release at the neuromuscular junction [53] and impairs neuromuscular conduction, causing transient muscle paralysis [20,73]. In a retrospective analysis, symptom improvement was reported by 35% of the patients [73].…”

“…Botulinum toxin A inhibits acetylcholine release at the neuromuscular junction [53] and impairs neuromuscular conduction, causing transient muscle paralysis [20,73]. In a retrospective analysis, symptom improvement was reported by 35% of the patients [73]. However, neither scintigraphy nor manometric parameters could predict treatment outcomes after botulinum toxin injection [73].…”

“…In a retrospective analysis, symptom improvement was reported by 35% of the patients [73]. However, neither scintigraphy nor manometric parameters could predict treatment outcomes after botulinum toxin injection [73]. Non-pyloric therapies, such as venting gastrostomy and gastric electrical stimulation (GES), have been reported to improve symptoms [11].…”