AGA Clinical Practice Update on Gastric Peroral Endoscopic Myotomy for Gastroparesis: Commentary

DescriptionThe purpose of this American Gastroenterological Association (AGA) Institute Clinical Practice Update (CPU) is to review the available evidence and provide expert advice regarding cognitive, procedural, and post-procedural aspects of performing gastric peroral endoscopic myotomy for the treatment of refractory gastroparesis.MethodsThis CPU was commissioned and approved by the AGA Institute Clinical Practice Updates Committee (CPUC) and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership and underwent internal peer review by the CPUC and external peer review through standard procedures of Gastroenterology. This expert commentary incorporates important as well as recently published studies in this field, and it reflects the experiences of the authors who are advanced endoscopists with expertise in treating patients by performing third-space endoscopy and gastric peroral endoscopic myotomy. The purpose of this American Gastroenterological Association (AGA) Institute Clinical Practice Update (CPU) is to review the available evidence and provide expert advice regarding cognitive, procedural, and post-procedural aspects of performing gastric peroral endoscopic myotomy for the treatment of refractory gastroparesis. This CPU was commissioned and approved by the AGA Institute Clinical Practice Updates Committee (CPUC) and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership and underwent internal peer review by the CPUC and external peer review through standard procedures of Gastroenterology. This expert commentary incorporates important as well as recently published studies in this field, and it reflects the experiences of the authors who are advanced endoscopists with expertise in treating patients by performing third-space endoscopy and gastric peroral endoscopic myotomy. Gastroparesis is a chronic gastrointestinal syndrome defined by symptomatic delayed gastric emptying of solid food, with or without delayed liquid emptying, which occurs in the absence of mechanical gastric-outlet obstruction.1Revicki D.A. Rentz A.M. Dubois D. et al.Development and validation of a patient-assessed gastroparesis symptom severity measure: the Gastroparesis Cardinal Symptom Index.Aliment Pharmacol Ther. 2003; 18: 141-150Crossref PubMed Scopus (303) Google Scholar,2Lacy B.E. Tack J. Gyawali C.P. AGA Clinical Practice Update on management of medically refractory gastroparesis: expert review.Clin Gastroenterol Hepatol. 2022; 20: 491-500Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar Failure of antral contractions and/or pyloric relaxation may impede gastric emptying, which is believed to be the main pathophysiological disturbance in gastroparesis, and manifests with symptoms of nausea, vomiting, early satiety, postprandial fullness, bloating, and upper abdominal pain.3Camilleri M. Sanders K.M. Gastroparesis. Gastroenterology. 2022; 162: 68-87.e1Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar Unfortunately, these symptoms overlap with those experienced by patients with functional dyspepsia, which makes accurate diagnosis and assessing treatment efficacy challenging.2Lacy B.E. Tack J. Gyawali C.P. AGA Clinical Practice Update on management of medically refractory gastroparesis: expert review.Clin Gastroenterol Hepatol. 2022; 20: 491-500Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar The pyloric sphincter is a zone of thickened muscularis propria with increased luminal pressure, approximately 1.2 cm wide, which straddles the gastric antrum and duodenum. Although pyloric contractions and relaxations are known to depend on transduction of neural signals by the interstitial cells of Cajal and conduction to smooth muscle cells, how the pyloric sphincter regulates gastric emptying is not fully known.3Camilleri M. Sanders K.M. Gastroparesis. Gastroenterology. 2022; 162: 68-87.e1Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar Pyloric dysfunction was described in patients with diabetes nearly 4 decades ago,4Mearin F. Camilleri M. Malagelada J.R. Pyloric dysfunction in diabetics with recurrent nausea and vomiting.Gastroenterology. 1986; 90: 1919-1925Abstract Full Text PDF PubMed Scopus (324) Google Scholar and diabetic neuropathy has been linked to antral hypomotility and pylorospasm, which is characterized by prolonged intermittent contractions and marked increases in baseline tone at the pylorus.3Camilleri M. Sanders K.M. Gastroparesis. Gastroenterology. 2022; 162: 68-87.e1Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar Refer to Table 1 for a list of potential causes of gastroparesis.Table 1Potential Causes of GastroparesisCauseDetailsEndocrineDiabetes accounts for approximately 25% of gastroparesis cases2Lacy B.E. Tack J. Gyawali C.P. AGA Clinical Practice Update on management of medically refractory gastroparesis: expert review.Clin Gastroenterol Hepatol. 2022; 20: 491-500Abstract Full Text Full Text PDF PubMed Scopus (23) Google ScholarPost-surgicalTypically due to partial or complete vagotomy, which may be intended or unintended (eg, esophagectomy, Billroth II gastrectomy, and fundoplication or hernia repair)Symptomatic gastroparesis is a common adverse event after lung or heart-lung transplantation, which may promote microaspiration into the lung allograft and contribute to graft failure5Vitton V. Benoit D'Journo X. Reynaud-Gaubert M. et al.Gastric peroral endoscopic myotomy (GPOEM) for severe gastroparesis after lung transplantation: a promising minimally invasive option.Clin Transplant. 2021; 35e14434Crossref PubMed Scopus (7) Google Scholar,6Podboy A.J. Clarke J.O. Nguyen L.A. et al.Gastric per-oral endoscopic myotomy for severe post-lung transplant gastroparesis: a single-center experience.J Heart Lung Transplant. 2020; 39: 1153-1156Abstract Full Text Full Text PDF PubMed Scopus (3) Google ScholarEndoscopic sleeve gastroplastyMay delay gastric emptying by constraining the middle and distal stomach3Camilleri M. Sanders K.M. Gastroparesis. Gastroenterology. 2022; 162: 68-87.e1Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar,7Abu Dayyeh B.K. Acosta A. Camilleri M. et al.Endoscopic sleeve gastroplasty alters gastric physiology and induces loss of body weight in obese individuals.Clin Gastroenterol Hepatol. 2017; 15: 37-43.e1Abstract Full Text Full Text PDF PubMed Scopus (173) Google ScholarMedicationsSeveral medications can delay gastric emptying (eg, anticholinergics and glucagon-like peptide-1 receptor agonists, which are used to treat diabetes and promote weight loss)8Parkman H.P. Idiopathic gastroparesis.Gastroenterol Clin North Am. 2015; 44: 59-68Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar,9Lacy B.E. Parkman H.P. Camilleri M. Chronic nausea and vomiting: evaluation and treatment.Am J Gastroenterol. 2018; 113: 647-659Crossref PubMed Scopus (47) Google ScholarOpioids can induce pyloric dysfunction and gastric stasis and are a common, iatrogenic, and potentially reversible cause of gastroparesis3Camilleri M. Sanders K.M. Gastroparesis. Gastroenterology. 2022; 162: 68-87.e1Abstract Full Text Full Text PDF PubMed Scopus (32) Google ScholarPost-viral gastroparesisUsually a self-limited disorder, although the course can be prolonged in some patientsIdiopathicThe most common form of gastroparesis2Lacy B.E. Tack J. Gyawali C.P. AGA Clinical Practice Update on management of medically refractory gastroparesis: expert review.Clin Gastroenterol Hepatol. 2022; 20: 491-500Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar Open table in a new tab Medically refractory gastroparesis has been defined as “persistent symptoms in the context of objectively confirmed gastric emptying delay, despite the use of dietary adjustment and metoclopramide as a first-line therapeutic agent.”2Lacy B.E. Tack J. Gyawali C.P. AGA Clinical Practice Update on management of medically refractory gastroparesis: expert review.Clin Gastroenterol Hepatol. 2022; 20: 491-500Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar Although endoscopic pyloric balloon dilation, intrapyloric botulinum toxin injection, gastric electrical stimulation, and transpyloric stenting have been used in patients who have not responded to medical therapy, published studies concerning these therapies have been inconsistent, shown no benefit, or lacked methodologic rigor.2Lacy B.E. Tack J. Gyawali C.P. AGA Clinical Practice Update on management of medically refractory gastroparesis: expert review.Clin Gastroenterol Hepatol. 2022; 20: 491-500Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar,10Ducrotte P. Coffin B. Bonaz B. et al.Gastric electrical stimulation reduces refractory vomiting in a randomized crossover trial.Gastroenterology. 2020; 158: 506-514.e2Abstract Full Text Full Text PDF PubMed Scopus (87) Google Scholar, 11Arts J. Holvoet L. Caenepeel P. et al.Clinical trial: a randomized-controlled crossover study of intrapyloric injection of botulinum toxin in gastroparesis.Aliment Pharmacol Ther. 2007; 26: 1251-1258Crossref PubMed Scopus (276) Google Scholar, 12Khashab M.A. Besharati S. Ngamruengphong S. et al.Refractory gastroparesis can be successfully managed with endoscopic transpyloric stent placement and fixation (with video).Gastrointest Endosc. 2015; 82: 1106-1109Abstract Full Text Full Text PDF PubMed Scopus (77) Google Scholar, 13Uemura K.L. Chaves D. Bernardo W.M. et al.Peroral endoscopic pyloromyotomy for gastroparesis: a systematic review and meta-analysis.Endosc Int Open. 2020; 8: E911-E923Crossref PubMed Google Scholar We refer the reader to the “AGA Clinical Practice Update on Management of Medically Refractory Gastroparesis: Expert Review”2Lacy B.E. Tack J. Gyawali C.P. AGA Clinical Practice Update on management of medically refractory gastroparesis: expert review.Clin Gastroenterol Hepatol. 2022; 20: 491-500Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar and our Supplementary Material for more information. As a natural extension of endoscopic submucosal dissection (ESD) and esophageal peroral endoscopic myotomy (E-POEM) for the treatment of achalasia,14Inoue H. Minami H. Kobayashi Y. et al.Peroral endoscopic myotomy (POEM) for esophageal achalasia.Endoscopy. 2010; 42: 265-271Crossref PubMed Scopus (1331) Google Scholar Kawai and colleagues15Kawai M. Peretta S. Burckhardt O. et al.Endoscopic pyloromyotomy: a new concept of minimally invasive surgery for pyloric stenosis.Endoscopy. 2012; 44: 169-173Crossref PubMed Scopus Google Scholar described the of gastric peroral endoscopic myotomy a in and M.A. Clarke J.O. et al.Gastric peroral endoscopic myotomy for refractory gastroparesis: endoscopic pyloromyotomy (with video).Gastrointest Endosc. Full Text Full Text PDF PubMed Scopus Google Scholar the in a in A. Nguyen L.A. et al.Gastric per-oral endoscopic and J Gastroenterol. PubMed Scopus Google Scholar peroral endoscopic be for patients with medically refractory gastroparesis. has been to be in treating patients with gastroparesis and P. S. L. et al.Gastric peroral endoscopic pyloromyotomy reduces increases of and reduces use for patients with Gastroenterol Hepatol. Full Text Full Text PDF PubMed Scopus Google Scholar with be and have gastric emptying patients with gastroparesis not be We to patients with refractory gastroparesis who have to no mechanical gastric-outlet a gastric emptying delayed gastric emptying, with at 4 and (3) have with nausea and vomiting as the who have gastric electrical therapy, pyloric and botulinum toxin injection be Failure of these therapies is not a to studies not after botulinum toxin injection or transpyloric stenting The gastric at 4 is is a M. and gastric for Gastroenterol Hepatol. Full Text Full Text PDF PubMed Scopus Google Scholar We to patients with gastric of at 4 as a study baseline gastric at 4 was of clinical Y. P. et al.Gastric per-oral endoscopic myotomy for refractory gastroparesis: 2022; PubMed Scopus Google Scholar The Gastroparesis Cardinal Symptom is used to the severity of D.A. Rentz A.M. Dubois D. et al.Development and validation of a patient-assessed gastroparesis symptom severity measure: the Gastroparesis Cardinal Symptom Index.Aliment Pharmacol Ther. 2003; 18: 141-150Crossref PubMed Scopus (303) Google Scholar and a to with a to the severity of important symptoms and The is into the nausea and vomiting postprandial and early and have the by the of the as to the P. S. L. et al.Gastric peroral endoscopic pyloromyotomy reduces increases of and reduces use for patients with Gastroenterol Hepatol. Full Text Full Text PDF PubMed Scopus Google D.A. Rentz A.M. Dubois D. et Cardinal Symptom and validation of a of severity of gastroparesis PubMed Scopus Google Scholar We to patients with symptoms refractory gastroparesis, which to a S. P. L. et and after gastric per-oral endoscopic pyloromyotomy (with video).Gastrointest Endosc. 2017; Full Text Full Text PDF PubMed Scopus Google Scholar The to to a be on the clinical and not by or our patients with nausea and vomiting are more to have a clinical to and patients who have abdominal are to Although pyloric and as by may have a in Y. J. et of endoscopic functional luminal in the of gastric peroral endoscopic pyloromyotomy (with video).Gastrointest Endosc. 2020; Full Text Full Text PDF PubMed Scopus Google et al.Gastric peroral endoscopic pyloromyotomy for gastroparesis: in to treatment Int Open. 2021; PubMed Google Scholar use of be Although has been used to treat pyloric in H. L. et al.Gastric peroral endoscopic pyloromyotomy for with pyloric J Gastroenterol. PubMed Scopus (3) Google Scholar is published evidence to on the and efficacy of performing for with gastroparesis. evidence is a promising minimally invasive for severe gastroparesis after lung V. Benoit D'Journo X. Reynaud-Gaubert M. et al.Gastric peroral endoscopic myotomy (GPOEM) for severe gastroparesis after lung transplantation: a promising minimally invasive option.Clin Transplant. 2021; 35e14434Crossref PubMed Scopus (7) Google Scholar,6Podboy A.J. Clarke J.O. Nguyen L.A. et al.Gastric per-oral endoscopic myotomy for severe post-lung transplant gastroparesis: a single-center experience.J Heart Lung Transplant. 2020; 39: 1153-1156Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar be by endoscopists with expertise or in third-space M.A. Clarke J.O. et al.Gastric peroral endoscopic myotomy for refractory gastroparesis: endoscopic pyloromyotomy (with video).Gastrointest Endosc. Full Text Full Text PDF PubMed Scopus Google M.A. peroral endoscopic pyloromyotomy for refractory Gastroenterol. 2017; 15: PubMed Google M. et al.Gastric peroral endoscopic pyloromyotomy for refractory gastroparesis: a systematic review of early with Endosc. 2020; Full Text Full Text PDF PubMed Scopus (43) Google Scholar Although in is not performing it the The of are to those of A. Nguyen L.A. et al.Gastric per-oral endoscopic and J Gastroenterol. PubMed Scopus Google M.A. peroral endoscopic pyloromyotomy for refractory Gastroenterol. 2017; 15: PubMed Google M.A. V. et al.Peroral endoscopic a to a Endosc. Full Text Full Text PDF PubMed Scopus Google Scholar is expertise in and are in and successfully performing on a liquid for at to gastric with efficacy be is with patients in the or We the as this for abdominal which can be managed with with a with a distal be used to for is and use of be of on and is for et Endosc. 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