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Reggie Nichols PA-SII
Ms. Diane Betes, 60 YOF with 23 year h/o type 2
DM, presents complaining of persistent nausea and vomiting for the last 6 months stating she "can't keep anything down." Most recent HbA1c reported to be "about 8." Reports passing gas, but states her "bowel movements have been very few and far between, but loose when they do come along." Endorses 10 lbs weight loss during this time. Denies hematemasis, heartburn, fever. Denies any aggravating factors. Describes emesis as consiting of "whatever I just ate."
Denies family history of cancer. Is a lifelong non-
smoker. States she is coming in now as she
"fears losing too much weight." States that
this has happened before, but that it
resolved with diet changes.
Risk Factors for Gastroparesis - Female, DM
Rule out mechanical factors - U/S, Scintigraphy
Ultrasound reveals no mass
Scintigraphy shows >70% of radiolabelled meal in stomach after 2 hours, and >35% after 4 hours
Gastroparesis is multifactorial, debilitating, and potentially life-threatening if left untreated. When due to an underlying neuropathy, treatment can be especially tricky.
1, 3
1, 4
Interstitial Cells of Cajal dysfunction
Pyloric obstruction
Nitric oxide synthesis/release defect
Parasympathetic dysfunction with Vagus Nerve injury
1, 3, 4
Malnutrition
Bezoars
Dehydration
Electrolyte disturbances
Hyper/hypoglycemia
4, 5
Conservative:
Dietary modifications (Liquid, Soft Foods)
Prokinetic agents (Metoclopramide, Erythromycin, Domperidone)
Surgical:
Intramuscular pyloric botulinum toxin injections
Gastric electrical stimulation
Transpyloric stenting
Gastrostomy tube insertion
Pyloromyotomy
Gastrectomy
What Ms. Betes has to say about these options:
"I've already changed my diet and Metoclopramide never worked for me before. I also heard that it gives you Parkinsons!"
"I don't want botox, that's toxic."
"Gastric pacemaker? I already have a cardiac pacemaker? Will they conflict? I don't feel comfortable with that."
"I don't like surgery. I don't want to be cut open. Is there some other way?"
6
2013 - First performed at John Hopkins
Modified POEM, for gastroparesis
instead of achalasia, consisting of 4 steps:
1. Mucosal incision - 5cm proximal to pylorus along
greater curvature
Mucosal bleb raised using 0.01% Epi and 0.25% indigo carmine in 0.9% saline
Recommend HybridKnife (water injection and electrocautery)
2. Submucosal tunnel creation - Spray coagulation with repeated blebing to enhance layer separation
Extends until visualization of pyloric muscle fibers
3. Myotomy - Selective myotomy of inner muscle fibers
Reduce risk of entering abdominal space
Circular muscle bundles are lifted towards submucosal tunnel by knife tip and divided with spray coagulation at 50 watts
4. Mucosal Closure - Endoscopic clips or endoluminal
suturing (via OverStitch)
Post-Op Care (not standardized):
NPO overnight with prophylactic antibiotics and antiemetics
Barium swallow the next day to exclude leak
Pending swallow eval, soft diet is allowed and encouraged for 10-14 days postop
1, 5, 7
207 patients across 8 studies
Upper GI Bleeding - 2
Peptic Ulceration - 4
Capnopertineum - 7
Abscess - 2
Pulmonary Embolism - 1
1, 2, 5, 7
100% technical success across all 207 patients.
Clinical success rate averaged at ~81%.
Predicted probability for dysphagia improvement after 12 months greater than traditional pyloromyotomy
Average procedural time was 53 minutes.
Average hospital stay was 2.9 days (range 1-5.4 days)
Longer than traditional pyloromyotomy (by 1 day)
7
4, 5
"The G-POEM technique has been successfully used to treat ... severe gastroparesis refractory to medical therapy."
Early retrospective studies look encouraging.
Despite this, more long-term studies are necessary to confirm results and establish guideline
recommendations that are standardized to
ensure safe practice.
1, 4, 5
1. Chung, Khashab. "Gastric Peroral Endoscopic Myotomy." 2018. Clin Endosc. 51(1):28-32.
2. Jacques et al. "Peroral Endoscopic Pyloromyotomy
is Efficacious and Safe for Refractory Gastroparesis." 2018. Endoscopy. DOI: 10.1055/a-0628-6639.
3. Kalaleh et al. "Gastric Peroral Endoscopic Myotomy for the Treatment of Refractory Gastroparesis." 2018. DOI: 10.1055/a-0596-7199.
4. Khoury et al. "State of the Art Review with Literature Summary on Gastric Peroral Endoscopic Pyloromyotomy for Gastroparesis." 2018. Journal of Gastroenterology
and Hepatology.
5. Su et al. ""Endoscopic Therapies for Gastroparesis." 2018. Current Gastroenterology Reports.
6. Khashab et al. "G-POEM for Refractory Gastroparesis:
First Human Endoscopic Pyloromyotomy." 2013. GIE
Journal.
7. UpToDate