Targeting the pylorus in gastroparesis: From physiology to endoscopic pyloromyotomy

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Abstract

Background

The pylorus plays a key role in the control of gastric content outflow. Impairment of pyloric physiology has been observed in gastroparesis, particularly when associated with diabetes mellitus or opioid intake or after antireflux surgery. New tools have been developed to identify pyloric dysfunction in routine care, including functional luminal impedance planimetry (FLIP). As such, a new therapeutic strategy targeting the pylorus, namely endoscopic pyloromyotomy (G‐POEM), has received increasing attention and emerged as a promising treatment for gastroparesis.

Purpose

The present review details the involvement of the pyloric pathophysiology in gastroparesis, as well as clinical results of G‐POEM according to the current literature.

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Most cited references 124

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A lexicon for endoscopic adverse events: report of an ASGE workshop.

Peter Cotton, Glenn M Eisen, Lars Aabakken … (2010)

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Clinical guideline: management of gastroparesis.

Michael Camilleri, Henry Parkman, Mehnaz Shafi … (2013)

This guideline presents recommendations for the evaluation and management of patients with gastroparesis. Gastroparesis is identified in clinical practice through the recognition of the clinical symptoms and documentation of delayed gastric emptying. Symptoms from gastroparesis include nausea, vomiting, early satiety, postprandial fullness, bloating, and upper abdominal pain. Management of gastroparesis should include assessment and correction of nutritional state, relief of symptoms, improvement of gastric emptying and, in diabetics, glycemic control. Patient nutritional state should be managed by oral dietary modifications. If oral intake is not adequate, then enteral nutrition via jejunostomy tube needs to be considered. Parenteral nutrition is rarely required when hydration and nutritional state cannot be maintained. Medical treatment entails use of prokinetic and antiemetic therapies. Current approved treatment options, including metoclopramide and gastric electrical stimulation (GES, approved on a humanitarian device exemption), do not adequately address clinical need. Antiemetics have not been specifically tested in gastroparesis, but they may relieve nausea and vomiting. Other medications aimed at symptom relief include unapproved medications or off-label indications, and include domperidone, erythromycin (primarily over a short term), and centrally acting antidepressants used as symptom modulators. GES may relieve symptoms, including weekly vomiting frequency, and the need for nutritional supplementation, based on open-label studies. Second-line approaches include venting gastrostomy or feeding jejunostomy; intrapyloric botulinum toxin injection was not effective in randomized controlled trials. Most of these treatments are based on open-label treatment trials and small numbers. Partial gastrectomy and pyloroplasty should be used rarely, only in carefully selected patients. Attention should be given to the development of new effective therapies for symptomatic control.

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Peroral endoscopic myotomy (POEM) for esophageal achalasia.

H. Inoue, H Minami, Y. Kobayashi … (2010)

Peroral endoscopic myotomy (POEM) was developed by our group to provide a less invasive permanent treatment for esophageal achalasia. POEM was performed in 17 consecutive patients with achalasia (10 men, 7 women; mean age 41.4 years). A long submucosal tunnel was created (mean length 12.4 cm), followed by endoscopic myotomy of circular muscle bundles of a mean total length of 8.1 cm (6.1 cm in distal esophagus and 2.0 cm in cardia). Smooth passage of an endoscope through the gastroesophageal junction was confirmed at the end of the procedure. In all cases POEM significantly reduced the dysphagia symptom score (from mean 10 to 1.3; P = 0.0003) and the resting lower esophageal sphincter (LES) pressure (from mean 52.4 mmHg to 19.9 mmHg; P = 0.0001). No serious complications related to POEM were encountered. During follow-up (mean 5 months), additional treatment or medication was necessary in only one patient (case 17) who developed reflux esophagitis (Los Angeles classification B); this was well controlled with regular intake of protein pump inhibitors (PPIs). The short-term outcome of POEM for achalasia was excellent; further studies on long-term efficacy and on comparison of POEM with other interventional therapies are awaited. Georg Thieme Verlag KG Stuttgart. New York.

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Author and article information

Contributors

Heithem Soliman:

ORCID: https://orcid.org/0000-0003-1644-7272

heithem.soliman@aphp.fr

Journal

Journal ID (nlm-ta): Neurogastroenterol Motil

Journal ID (iso-abbrev): Neurogastroenterol Motil

Journal ID (doi): 10.1111/(ISSN)1365-2982

Journal ID (publisher-id): NMO

Title: Neurogastroenterology and Motility

Publisher: John Wiley and Sons Inc. (Hoboken )

ISSN (Print): 1350-1925

ISSN (Electronic): 1365-2982

Publication date (Electronic): 03 January 2023

Publication date (Print): February 2023

Volume: 35

Issue: 2 ( doiID: 10.1111/nmo.v35.2 )

Electronic Location Identifier: e14529

Affiliations

[ ¹ ] Physiology Department, INSERM UMR 1073, CIC‐CRB 1404 Centre Hospitalo‐Universitaire de Rouen Rouen France

[ ² ] Département d'Hépato‐Gastro‐Entérologie, Hôpital Louis Mourier, AP‐HP Nord Université de Paris Cité Colombes France

Author notes

[*] [* ] Correspondence

Heithem Soliman, Physiology Department, INSERM UMR 1073, CIC‐CRB 1404, Centre Hospitalo‐Universitaire de Rouen, Rouen, France.

Email: heithem.soliman@ 123456aphp.fr

Author information

Heithem Soliman https://orcid.org/0000-0003-1644-7272

Guillaume Gourcerol https://orcid.org/0000-0001-8220-9155

Article

Publisher ID: NMO14529 Other ID: NMO-00160-2022.R1

DOI: 10.1111/nmo.14529

PMC ID: 10077918

PubMed ID: 36594414

SO-VID: 80e5614c-46f9-40ac-9e89-ffe0ae14e280

License:

This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc-nd/4.0/ License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.

History

Date revision received : 28 August 2022

Date received : 29 April 2022

Date accepted : 19 December 2022

Page count

Figures: 3, Tables: 1, Pages: 13, Words: 9215

Custom metadata

source-schema-version-number 2.0

cover-date February 2023

details-of-publishers-convertor Converter:WILEY_ML3GV2_TO_JATSPMC version:6.2.7 mode:remove_FC converted:06.04.2023

ScienceOpen disciplines: Gastroenterology & Hepatology

Keywords: endoflip,gastric motility,gastroparesis,g‐poem,pyloromyotomy,pylorospasm

Data availability:

ScienceOpen disciplines: Gastroenterology & Hepatology

Keywords: endoflip, gastric motility, gastroparesis, g‐poem, pyloromyotomy, pylorospasm

Targeting the pylorus in gastroparesis: From physiology to endoscopic pyloromyotomy

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Abstract

Background

Purpose

Related collections

Karger: Gastroenterology

Most cited references 124

A lexicon for endoscopic adverse events: report of an ASGE workshop.

Clinical guideline: management of gastroparesis.

Peroral endoscopic myotomy (POEM) for esophageal achalasia.

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