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Clinical efficacy of gastric per-oral endoscopic myotomy (G-POEM) in the treatment of refractory gastroparesis and predictors of outcomes: a systematic review and meta-analysis using surgical pyloroplasty as a comparator group

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Abstract

Background and aims

Gastric peroral endoscopic myotomy (G-POEM) is a novel minimally invasive technique in endosurgery. Data is limited as to its efficacy, safety, and predictive factors. We conducted this meta-analysis to evaluate the clinical outcomes of G-POEM and used the outcomes of surgical pyloroplasty as a comparator group in the treatment of refractory gastroparesis.

Methods

We searched multiple databases from inception through March 2019 to identify studies that reported on G-POEM and pyloroplasty in gastroparesis. Our primary outcome was to analyze and compare the pooled rates of clinical success, in terms of Gastroparesis Cardinal Symptom Index (GCSI) score and 4-h gastric emptying study (GES) results, with G-POEM and pyloroplasty.

Results

Three hundred and thirty-two and 375 patients underwent G-POEM (11 studies) and surgical pyloroplasty (seven studies), respectively. The pooled rate of clinical success, based on the GCSI score, with G-POEM was 75.8% (95% CI 68.1–82.1, I2 = 50) and with surgical pyloroplasty was 77.3% (95% CI 66.4–85.4, I2 = 0), with no significance, p = 0.81. The pooled rate of clinical success, based on the 4-hour GES results, with G-POEM was 85.1% (95% CI 68.9–93.7, I2 = 74) and with surgical pyloroplasty was 84% (95% CI 64.4–93.8, I2 = 81), with no significance, p = 0.91. The overall adverse events were comparable. Based on meta-regression analysis, idiopathic gastroparesis, prior treatment with botulinum toxin and gastric stimulator seemed to predict clinical success with G-POEM.

Conclusion

G-POEM demonstrates clinical success in treating refractory gastroparesis. Idiopathic gastroparesis, prior treatment with botulinum injections and gastric stimulator appear to have positive predictive effects on the 4-h GES results after G-POEM. Outcomes seem comparable to surgical pyloroplasty.

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Abbreviations

G-POEM:

Gastric peroral endoscopic myotomy

POP:

Peroral pyloromyotomy

GCSI:

Gastroparesis Cardinal Symptom Index

GES:

Gastric emptying study

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Acknowledgements

Danielle J. Gerberi, MLS, AHIP (Librarian, Mayo Clinic Libraries, Rochester, Minnesota) for help with database search.

Funding

No funding was used for this study.

Author information

Author notes

  1. Babu P. Mohan and Saurabh Chandan contributed equally to the manuscript.

Authors and Affiliations

  1. Internal Medicine, Banner University Medical Center, University of Arizona, Tucson, AZ, USA

    Babu P. Mohan, Shahab R. Khan & Rajesh Kotagiri

  2. Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, NE, USA

    Saurabh Chandan, Lokesh K. Jha, Neil Bhogal, Ishfaq Bhat & Alexander T. Hewlett

  3. Internal Medicine, Mayo Clinic, Rochester, MN, USA

    Lena L. Kassab

  4. Internal Medicine, Buffalo General Hospital, University at Buffalo, Buffalo, NY, USA

    Naveen P. G. Ravikumar

  5. Pediatric Gastroenterology, Hepatology & Nutrition, University of Nebraska Medical Center, Omaha, NE, USA

    Ojasvini C. Chandan

  6. Limoges University Hospital, University of Limoges, Limoges, France

    Jeremie Jacques

  7. Internal Medicine, Carilion Roanoke Memorial Hospital, Roanoke, VA, USA

    Suresh Ponnada

  8. Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore, Singapore

    Ravishankar Asokkumar

  9. Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, UT, USA

    Douglas G. Adler

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  1. Babu P. Mohan
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Contributions

BPM, SC, NR, and LKJ: conception and design, drafting of article. BPM, RK, SC, LLK, NR, LKJ: study search, review and selection. BPM, SC, SRK, NR, OCC, NB, LKJ, and JJ: data collection and synthesis. BPM, SP: statistical analysis of data and interpretation of results. JJ, IB, ATH, RA, and DGA: critical revision of the article for important intellectual content and final approval of the article.

Corresponding author

Correspondence to Douglas G. Adler.

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Disclosures

Dr. Jeremie Jacques is a consultant for Olympus and Boston Scientific. Dr. Douglas G. Adler is a consultant to Boston Scientific. Drs. Babu P. Mohan, Saurabh Chandan, Lokesh Jha, Shahab R. Khan, Rajesh Kotagiri, Lena L. Kassab, Naveen PG. Ravikumar, Neil Bhogal, Ojasvini C. Chandan, Ishfaq Bhat, Alexander Hewlett, Jeremie Jacques, Suresh Ponnada, and Ravishankar Asokkumar declare that they have no conflicts of interest or financial ties to disclose.

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Appendix

Appendix

Literature search strategy

ClinicalTrials.gov

Peroral myotomy | gastroparesis

EBM reviews

(((((peroral* or per-oral*) adj3 (myotom* or pyloromyotom* or pylormyotomy)) or POEM or G-POEM or POP).ab,hw,ti. OR (“natural orifice” adj2 endoscop*).ab,hw,ti.) OR ((pyloroplasty or pylorplasty or pyloroduodenotomy or pyloromyoplasty or rammstedt) and laparoscop*).ab,hw,ti.) AND (gastroparesis or gastroplegia or “delayed gastric emptying” or “delayed stomach emptying” or ((gastric* or stomach*) adj2 (aton* or paraly* or pares* or stas*))).ab,hw,ti.

Embase (1974 +)

(((exp peroral endoscopic myotomy/ OR (((peroral* or per-oral*) adj3 (myotom* or pyloromyotom* or pylormyotomy)) or POEM or G-POEM or POP).ab,kw,ti. OR (“natural orifice” adj2 endoscop*).ab,kw,ti.) OR ((exp laparoscopy/ OR “laparoscop*”.ab,kw,ti.) AND (exp pyloroplasty/ OR (pyloroplasty or pylorplasty or pyloroduodenotomy or pyloromyoplasty or rammstedt).ab,kw,ti.))) AND (exp stomach paresis/ OR (gastroparesis or gastroplegia or “delayed gastric emptying” or “delayed stomach emptying” or ((gastric* or stomach*) adj2 (aton* or paraly* or pares* or stas*))).ab,kw,ti.)) NOT child/ not adult/ NOT exp animal/ not exp human/

Ovid MEDLINE(R) 1946 to present and epub ahead of print, in-process & other non-indexed citations and ovid MEDLINE(R) daily

(((exp Natural Orifice Endoscopic Surgery/ OR (((peroral* or per-oral*) adj3 (myotom* or pyloromyotom* or pylormyotomy)) or POEM or G-POEM or POP).ab,kf,ti. OR (“natural orifice” adj2 endoscop*).ab,kf,ti.) OR ((exp Laparoscopy/ OR”laparoscop*”.ab,kf,ti.) AND ((pyloroplasty or pylorplasty or pyloroduodenotomy or pyloromyoplasty or rammstedt).ab,kf,ti.))) AND (exp Gastroparesis/ OR (gastroparesis or gastroplegia or “delayed gastric emptying” or “delayed stomach emptying” or ((gastric* or stomach*) adj2 (aton* or paraly* or pares* or stas*))).ab,kf,ti.) NOT exp CHILD/ not exp ADULT/ NOT exp Animals/ not Humans/

Scopus

( ( ( TITLE-ABS-KEY ( ( ( ( peroral*  OR  per-oral* )  W/3  ( myotom*  OR  pyloromyotom*  OR  pylormyotomy ) )  OR  poem  OR  g-poem  OR  pop ) )  OR  TITLE-ABS-KEY ( ( ”natural orifice”  W/2  endoscop* ) ) ) )  AND  ( TITLE-ABS-KEY ( ( gastroparesis  OR  gastroplegia  OR  ”delayed gastric emptying”  OR  ”delayed stomach emptying”  OR  ( ( gastric*  OR  stomach* )  W/2  ( aton*  OR  paraly*  OR  pares*  OR  stas* ) ) ) ) ) )  OR  ( ( TITLE-ABS-KEY ( ( gastroparesis  OR  gastroplegia  OR  ”delayed gastric emptying”  OR  ”delayed stomach emptying”  OR  ( ( gastric*  OR  stomach* )  W/2  ( aton*  OR  paraly*  OR  pares*  OR  stas* ) ) ) ) )  AND  ( TITLE-ABS-KEY ( ( pyloroplasty  OR  pylorplasty  OR  pyloroduodenotomy  OR  pyloromyoplasty  OR  rammstedt )  AND  laparoscop* ) ) )  AND  ( LIMIT-TO ( LANGUAGE ,  ”English” ) )  AND  ( LIMIT-TO ( SRCTYPE ,  ”j” ) ) 

Web of science

(TOPIC: ((((peroral* or per-oral*) NEAR/3 (myotom* or pyloromyotom* or pylormyotomy)) or POEM or G-POEM or POP)) OR TOPIC: (“natural orifice” NEAR/2 endoscop*) OR TOPIC: ((pyloroplasty or pylorplasty or pyloroduodenotomy or pyloromyoplasty or rammstedt) AND laparoscop*)) AND TOPIC: ((gastroparesis or gastroplegia or “delayed gastric emptying” or “delayed stomach emptying” or ((gastric* or stomach*) NEAR/2 (aton* or paraly* or pares* or stas*))))

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Mohan, B.P., Chandan, S., Jha, L.K. et al. Clinical efficacy of gastric per-oral endoscopic myotomy (G-POEM) in the treatment of refractory gastroparesis and predictors of outcomes: a systematic review and meta-analysis using surgical pyloroplasty as a comparator group. Surg Endosc 34, 3352–3367 (2020). https://doi.org/10.1007/s00464-019-07135-9

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