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EndoFLIP and Pyloric Dilation for Gastroparesis Symptoms Refractory to Pyloromyotomy/Pyloroplasty

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Abstract

Background

Gastroparesis patients may undergo pyloromyotomy/pyloroplasty for chronic refractory symptoms. However, some patients have persistent symptoms. It is unknown if balloon dilation may improve their symptoms.

Aims

We aimed to (1) assess if pyloric through-the-scope (TTS) balloon dilation results in symptom improvement in gastroparesis patients with suboptimal response to pyloromyotomy/pyloroplasty and (2) determine endoscopic functional luminal imaging probe (EndoFLIP) characteristics of these patients before dilation.

Methods

Patients with severe gastroparesis refractory to pyloromyotomy/pyloroplasty seen from 2/2019 to 3/2020 underwent pyloric TTS dilation after assessing the pyloric characteristics using EndoFLIP. Patients completed Gastroparesis Cardinal Symptom Index (GCSI) pre-procedurally, and GCSI and Clinical Patient Grading Assessment Scale (CPGAS) on follow-ups.

Results

Thirteen (ten females) patients (mean age 45.2 ± 5.1 years) with severe gastroparesis symptoms (mean GCSI total score 3.4 ± 0.3) after pyloromyotomy/pyloroplasty underwent pyloric TTS dilation. Overall, there was improvement in symptoms at 1-month follow-up (mean GCSI total score 3.0 ± 0.4, mean CPGAS score 1.6 ± 0.5, p < 0.05 for both), with five (38%) patients reporting symptoms somewhat/moderately better. The patients with symptom improvement had lower pre-dilation pyloric EndoFLIP distensibility at 30 ml, 40 ml, and 50 ml than patients with little/no improvement (all p < 0.05).

Conclusions

In gastroparesis patients with refractory symptoms after pyloromyotomy/pyloroplasty, pyloric TTS dilation improved symptoms in about a third of the patients. Patients with symptom improvement had lower pre-dilation pyloric distensibility on EndoFLIP suggesting incomplete myotomy, pyloric muscle regeneration, or pyloric stricture. Pyloric EndoFLIP followed by TTS dilation seems to be a promising treatment for some patients with gastroparesis symptoms refractory to pyloromyotomy/pyloroplasty.

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References

  1. Parkman HP, Hasler WL, Fisher RS, American Gastroenterological Association. American Gastroenterological Association medical position statement: diagnosis and treatment of gastroparesis. Gastroenterology. 2004;127:1589–1591.

    Article  Google Scholar 

  2. 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.

    Article  CAS  Google Scholar 

  3. Rey E, Choung RS, Schleck CD, Zinsmeister AR, Talley NJ, Locke GR. Prevalence of hidden gastroparesis in the community: the gastroparesis “iceberg”. J Neurogastroenterol Motil. 2012;18:34–42.

    Article  Google Scholar 

  4. Jehangir A, Parkman HP. Rome IV diagnostic questionnaire complements patient assessment of gastrointestinal symptoms for patients with gastroparesis symptoms. Dig Dis Sci. 2018;63:2231–2243. https://doi.org/10.1007/s10620-018-5125-1.

    Article  PubMed  Google Scholar 

  5. Yu D, Ramsey FV, Norton WF, et al. The burdens, concerns, and quality of life of patients with gastroparesis. Dig Dis Sci. 2017;62:879–893. https://doi.org/10.1007/s10620-017-4456-7.

    Article  PubMed  Google Scholar 

  6. Jehangir A, Collier A, Shakhatreh M, Malik Z, Parkman HP. Caregiver burden in gastroparesis and GERD: correlation with disease severity, healthcare utilization and work productivity. Dig Dis Sci. 2019;64:3451–3462. https://doi.org/10.1007/s10620-019-05723-2.

    Article  CAS  PubMed  Google Scholar 

  7. Jehangir A, Parkman HP. Gastroparesis. In: Encyclopedia of gastroenterology. 2nd ed. Cambridge, MA: Academic Press; p. 720–30.

  8. 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 Basic Clin. 2017;202:56–61.

    Article  Google Scholar 

  9. Kim J-H, Lee H-S, Kim MS, Lee JM, Kim SK, Zo JI. Balloon dilatation of the pylorus for delayed gastric emptying after esophagectomy. Eur J Cardio-Thorac Surg. 2008;33:1105–1111.

    Article  Google Scholar 

  10. Gourcerol G, Tissier F, Melchior C, et al. Impaired fasting pyloric compliance in gastroparesis and the therapeutic response to pyloric dilatation. Aliment Pharmacol Ther. 2015;41:360–367.

    Article  CAS  Google Scholar 

  11. Desprez C, Melchior C, Wuestenberghs F, et al. Pyloric distensibility measurement predicts symptomatic response to intrapyloric botulinum toxin injection. Gastrointest Endosc. 2019;90:754.e1–760.e1.

    Article  Google Scholar 

  12. Shada AL, Dunst CM, Pescarus R, et al. Laparoscopic pyloroplasty is a safe and effective first-line surgical therapy for refractory gastroparesis. Surg Endosc. 2016;30:1326–1332.

    Article  Google Scholar 

  13. Malik Z, Kataria R, Modayil R, et al. Gastric per oral endoscopic myotomy (G-POEM) for the treatment of refractory gastroparesis: early experience. Dig Dis Sci. 2018;63:2405–2412. https://doi.org/10.1007/s10620-018-4976-9.

    Article  PubMed  Google Scholar 

  14. Mekaroonkamol P, Li LY, Dacha S, et al. Gastric peroral endoscopic pyloromyotomy (G-POEM) as a salvage therapy for refractory gastroparesis: a case series of different subtypes. Neurogastroenterol Motil. 2016;28:1272–1277.

    Article  CAS  Google Scholar 

  15. Shlomovitz E, Pescarus R, Cassera MA, et al. Early human experience with per-oral endoscopic pyloromyotomy (POP). Surg Endosc. 2015;29:543–551.

    Article  Google Scholar 

  16. Gonzalez J-M, Lestelle V, Benezech A, et al. Gastric per-oral endoscopic myotomy with antropyloromyotomy in the treatment of refractory gastroparesis: clinical experience with follow-up and scintigraphic evaluation (with video). Gastrointest Endosc. 2017;85:132–139.

    Article  Google Scholar 

  17. Dacha S, Mekaroonkamol P, Li L, et al. Outcomes and quality-of-life assessment after gastric per-oral endoscopic pyloromyotomy (with video). Gastrointest Endosc. 2017;86:282–289.

    Article  Google Scholar 

  18. Khashab MA, Ngamruengphong S, Carr-Locke D, et al. 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.

    Article  Google Scholar 

  19. Jacques J, Pagnon L, Hure F, et al. Peroral endoscopic pyloromyotomy is efficacious and safe for refractory gastroparesis: prospective trial with assessment of pyloric function. Endoscopy. 2019;51:40–49.

    Article  Google Scholar 

  20. Hedberg HM, Carbray J, Ujiki MB. Initial experience with endoscopic pyloromyotomy, with description and video of technique. J Gastrointest Surg. 2019;23:1706–1710.

    Article  Google Scholar 

  21. Vosoughi K, Ichkhanian Y, Jacques J, et al. Role of endoscopic functional luminal imaging probe in predicting the outcome of gastric peroral endoscopic pyloromyotomy (with video). Gastrointest Endosc. 2020;91:1289–1299.

    Article  Google Scholar 

  22. Zoll B, Jehangir A, Edwards MA, et al. Surgical treatment for refractory gastroparesis: stimulator, pyloric surgery, or both? J Gastrointest Surg. 2019;. https://doi.org/10.1007/s11605-019-04391-x.

    Article  PubMed  Google Scholar 

  23. Watkins PJ, Buxton-Thomas MS, Howard ER. Long-term outcome after gastrectomy for intractable diabetic gastroparesis. Diabet Med J Br Diabet Assoc. 2003;20:58–63.

    Article  CAS  Google Scholar 

  24. Zehetner J, Ravari F, Ayazi S, et al. Minimally invasive surgical approach for the treatment of gastroparesis. Surg Endosc. 2013;27:61–66.

    Article  Google Scholar 

  25. Revicki DA, Rentz AM, Dubois D, et al. Gastroparesis Cardinal Symptom Index (GCSI): development and validation of a patient reported assessment of severity of gastroparesis symptoms. Qual Life Res. 2004;13:833–844.

    Article  Google Scholar 

  26. Midani D, Parkman HP. Granisetron transdermal system for treatment of symptoms of gastroparesis: a prescription registry study. J Neurogastroenterol Motil. 2016;22:650–655.

    Article  Google Scholar 

  27. Pasricha PJ, Yates KP, Nguyen L, et al. Outcomes and factors associated with reduced symptoms in patients with gastroparesis. Gastroenterology. 2015;149:1762.e4–1774.e4.

    Google Scholar 

  28. Tougas G, Eaker EY, Abell TL, et al. Assessment of gastric emptying using a low fat meal: establishment of international control values. Am J Gastroenterol. 2000;95:1456–1462.

    Article  CAS  Google Scholar 

  29. Clarke JO, McCallum RW. Endoscopic approaches for gastroparesis. In: Ginsberg GG, Kochman ML, Norton ID, Gostout CJ, eds. Clinical gastrointestinal endoscopy E-Book. Amsterdam: Elsevier; 2018:322–329.

    Google Scholar 

  30. Ata-Lawenko RM, Lee YY. Emerging roles of the endolumenal functional lumen imaging probe in gastrointestinal motility disorders. J Neurogastroenterol Motil. 2017;23:164–170.

    Article  Google Scholar 

  31. Gregersen H, Drewes AM, McMahon BP, Liao D. Balloon-distension studies in the gastrointestinal tract: current role. Dig Dis. 2006;24:286–296.

    Article  Google Scholar 

  32. Saadi M, Yu D, Malik Z, Parkman HP, Schey R. Pyloric sphincter characteristics using EndoFLIP® in gastroparesis. Rev Gastroenterol Mex. 2018;83:375–384.

    CAS  Google Scholar 

  33. Malik Z, Sankineni A, Parkman HP. Assessing pyloric sphincter pathophysiology using EndoFLIP in patients with gastroparesis. Neurogastroenterol Motil. 2015;27:524–531.

    Article  CAS  Google Scholar 

  34. Jehangir A, Parkman HP. Role of gastric emptying in symptoms of gastroparesis. Gastrointest Disord. 2019;1:391–402.

    Article  Google Scholar 

  35. Heckert J, Sankineni A, Hughes WB, Harbison S, Parkman H. Gastric electric stimulation for refractory gastroparesis: a prospective analysis of 151 patients at a single center. Dig Dis Sci. 2016;61:168–175. https://doi.org/10.1007/s10620-015-3837-z.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Gastroenterology Section, Department of Medicine, Temple University School of Medicine, Philadelphia, PA, USA

    Asad Jehangir, Zubair Malik & Henry P. Parkman

  2. Department of Thoracic Surgery, Temple University School of Medicine, Philadelphia, PA, USA

    Roman V. Petrov

Authors
  1. Asad Jehangir
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  2. Zubair Malik
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  3. Roman V. Petrov
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  4. Henry P. Parkman
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Contributions

AJ collected and analyzed the data, did literature review, and wrote manuscript. ZM evaluated patients included in the study, performed EndoFLIP and TTS pyloric dilations, and helped with manuscript preparation. RVP evaluated patients included in the study, performed pyloromyotomy/pyloroplasty, and helped with manuscript preparation. HPP planned and supervised the study, evaluated patients included in the study, performed EndoFLIP and TTS pyloric dilations, and did literature review and critical revision of the manuscript for important intellectual content. All authors approve the final version of the manuscript.

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Correspondence to Henry P. Parkman.

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Jehangir, A., Malik, Z., Petrov, R.V. et al. EndoFLIP and Pyloric Dilation for Gastroparesis Symptoms Refractory to Pyloromyotomy/Pyloroplasty. Dig Dis Sci 66, 2682–2690 (2021). https://doi.org/10.1007/s10620-020-06510-0

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  • DOI: https://doi.org/10.1007/s10620-020-06510-0

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