Pyloric dilation with the esophageal functional lumen imaging probe in gastroparesis improves gastric emptying, pyloric distensibility, and symptoms

Murray, Fritz Ruprecht; Schindler, Valeria; Hente, Juliane; Fischbach, Lara Maria; Schnurre, Larissa; Deibel, Ansgar; Hildenbrand, Florian F.; Tatu, Aurora; Pohl, Daniel

doi:10.1016/j.gie.2021.03.022

Cited by 21 publications

(10 citation statements)

References 35 publications

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“…Pyloric botulinum toxin (Botox) injection and pneumatic dilation are thought to work by a similar mechanism [12][13][14]. The efficacy of dilation and Botox as stand-alone treatments is controversial [3,15,16]. In fact, their use is not recommended in the most recent guidelines by the American College of Gastroentology [3].…”

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confidence: 99%

Predictors of favorable outcome after pyloroplasty for gastroparesis: should response to pyloric dilation or Botox injection be used as a marker of surgical outcome?

et al. 2023

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Introduction Pyloroplasty and gastric peroral endoscopic myotomy (G-POEM) are effective surgeries for gastroparesis. The primary aim of this study was to evaluate outcomes of pyloroplasty and G-POEM in patients with gastroparesis and determine factors associated with favorable outcome. The secondary aim was to assess the utility of clinical response to preoperative pyloric dilation or botulinum toxin injection (Botox) on surgical outcome, a factor conventionally used as a favorable marker. Methods There were 204 patients who underwent pyloroplasty (n = 177) or G-POEM (n = 27) for gastroparesis at our institution from 2014 to 2021. Demographic and clinical parameters were analyzed to assess their impact on surgical outcome. A subgroup of patients who had pyloric dilation or Botox injection were assessed separately. Favorable outcome was defined as patient reported complete resolution of the predominant gastroparesis symptom. Results Favorable outcome was achieved in 78.4% of patients (pyloroplasty: 79.7% and G-POEM: 70.4%, p = 0.274). Among 61 patients where pre- and postoperative gastric emptying studies (GES) were available, mean 4-hour retention significantly improved from 33.5 to 15.0% (p < 0.001) and 77.0% of patients achieved normalization. Favorable outcome was not significantly impacted by etiology of gastroparesis (p = 0.120), GERD (p = 0.518), or primary gastroparesis symptom (p = 0.244). Age ≥ 40 was a significant predictor of favorable surgical outcome on multivariate analysis [OR: 2.476 (1.224–5.008), p = 0.012]. Among the patients who had preoperative dilation (n = 82) or Botox injection (n = 46), response to these interventions was not a predictor of favorable surgical outcome (p = 0.192 and 0.979, respectively). However, preoperative Botox injection, regardless of response to injection, was associated with favorable surgical outcome [OR: 3.205 (CI 1.105–9.299), p = 0.032]. Conclusion Symptomatic improvement after pyloroplasty or G-POEM is independent of etiology of gastroparesis, GERD, and primary symptom. Response to dilation or Botox are not markers of response to surgery. However, patients who receive Botox are 3.2 times more likely to improve postoperatively. Graphical abstract

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confidence: 99%

Predictors of favorable outcome after pyloroplasty for gastroparesis: should response to pyloric dilation or Botox injection be used as a marker of surgical outcome?

et al. 2023

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“… 111 Subsequent studies on impedance planimetry measurements reaffirmed similar correlation between an increased pyloric distensibility and improved gastroparesis symptoms, whether the pyloromyotomy was performed by G-POEM or by an EsoFLIP-controlled pyloric dilation. 127 - 129 Gastric emptying was also found to be decreased after G-POEM when improved pyloric indices and symptoms were observed. 129 , 130 Although there is prognostic benefit of intra-procedural pyloric evaluation using EndoFLIP Ⓡ , the cost-effectiveness of its routine use remains to be further verified.…”

Section: Treatmentmentioning

confidence: 88%

A New Paradigm Shift in Gastroparesis Management

2022

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Gastroparesis, once regarded as a rare disease, is difficult to diagnose and challenging to treat; there were many breakthrough advances in the 2010s, shifting the paradigm of the understanding of this complex entity and its management. Similar to diabetes, its increasing prevalence reflects increased accessibility to diagnostic modalities and suggests that gastroparesis was underacknowledged in the past. Major developments in the three main aspects of the disease include the discovery of smooth muscle cells, interstitial cells of Cajal, PDGFRα + cells syncytium, rather than interstitial cells of Cajal alone, as the main gastric pacemaker unit; the development of validated point-of-care diagnostic modalities such as a wireless motility capsule, the carbon 13-labeled breath test, and impedance planimetry; and the introduction of novel minimally invasive therapeutic options such as newer pharmacologic agents and gastric peroral endoscopic pyloromyotomy. All aspects of these advances will be discussed further in this review.

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“…No complications were shown with the hydraulic balloon dilation, used up to 20 mm. Recently, the EsoFLIP, combining EndoFlip measurement, and hydraulic dilation at a diameter up to 30 mm have been assessed and led to a symptomatic improvement in 57% of patients at 4 months 65 . The study by Jehangir et al reported symptomatic improvement with pyloric dilation after a previous pylorotomy in 5 patients out of 13 63 .…”

Section: Endoscopic Therapies Targeting the Pylorusmentioning

confidence: 99%

Targeting the pylorus in gastroparesis: From physiology to endoscopic pyloromyotomy

Soliman

Gourcerol

2023

Neurogastroenterology Motil

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Gastroparesis is defined as delayed gastric emptying (GE) of solid food in the absence of mechanical obstruction. 1 Cardinal symptoms include nausea, vomiting, gastric fullness, early satiety, bloating, and abdominal pain/discomfort. 2 These symptoms can overlap with those of functional dyspepsia, but gastroparesis has to be confirmed by an objective measurement of GE, either by scintigraphy, or by 13 Coctanoic acid breath test. The prevalence of diagnosed gastroparesis has been evaluated in the United States at 0.24% of the population. 3 Recent epidemiological data from the United Kingdom confirm a similar prevalence of 0.13% in Europe based on the diagnostic code, although the disease appears to be underdiagnosed. 4 Gastroparesis leads to an economic burden, evaluated between US$4000 and US$9000 per patient per year in a recent study. 5 Moreover, delayed GE has been associated with increased mortality, independently of age, sex, or the etiology of the disease. 6 The first-line treatment relies on dietary modification and medical treatment, with prokinetic drugs such as metoclopramide. 7,8 However, the efficacy of medical treatment is limited, and up to 40% of patients are considered to be refractory after appropriate treatment. 9 Severe refractory gastroparesis can lead to dehydration, weight loss, and impaired quality of life and could become a challenging condition. 10 Thus, invasive techniques have been developed to improve the symptoms of such patients.Considering the role of pyloric dysfunction in gastroparesis, 11 gastric peroral endoscopic pyloromyotomy (G-POEM) has emerged as an alternative therapeutic technique in patients with refractory gastroparesis. The first human case was described in 2013 by Khashab et al. 12 The technique is based on the principles of peroral endoscopic myotomy of the lower esophageal sphincter, used to treat achalasia. Since then, cohort studies have assessed the clinical efficacy and the safety of G-POEM in refractory gastroparesis.This review aims to detail the role of the pylorus in the pathophysiology of gastroparesis, and then to report the efficacy, modalities, and the place of G-POEM, based on the results of published studies.

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Pyloric dilation with the esophageal functional lumen imaging probe in gastroparesis improves gastric emptying, pyloric distensibility, and symptoms

Cited by 21 publications

References 35 publications

Predictors of favorable outcome after pyloroplasty for gastroparesis: should response to pyloric dilation or Botox injection be used as a marker of surgical outcome?

Predictors of favorable outcome after pyloroplasty for gastroparesis: should response to pyloric dilation or Botox injection be used as a marker of surgical outcome?

A New Paradigm Shift in Gastroparesis Management

Targeting the pylorus in gastroparesis: From physiology to endoscopic pyloromyotomy

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