GPOEM for Gastroparesis: Offering Hope to Patients

Gastroparesis is one of the most vexing conditions that patients can face and we, as physicians, struggle to treat. While commonly thought of as a sequela of poorly controlled diabetes, gastroparesis can also arise secondary to surgical injury to the vagus nerve (most commonly encountered after fundoplication). Gastroparesis can also develop after a gastrointestinal infection, as a manifestation of dysautonomia, or may be idiopathic. Douglas G. Adler, MDWell-meaning clinicians often start patients on a so-called “gastroparesis diet.” These diets, which emphasize frequent meals, small portions, and liquid caloric intake, can be effective but are very challenging to adhere to in the real world. People have teeth and they want to chew their food, not just drink it in the form of protein shakes. In my experience most patients either abandon their gastroparesis diets in short order or verbalize a higher degree of compliance than they manifest in real life (just try drinking only protein shakes for a few days and see how long you last). Promotility agents such as metoclopramide and prucalopride are effective but come with significant risks for cardiovascular and neurologic side effects. Many patients are hesitant to use these agents after reading about them online. Still, gastroparesis is so disabling that some patients will accept the risk for arrhythmia and tardive dyskinesia to treat it with these drugs. Agents to stimulate gastric motility such as erythromycin are safer, but in my experience are also less effective. Pyloric botulinum toxin injection, used to promote gastric outflow, is safe but effects have been variable in studies. Still, many patients find their way to Botox injections, which must be periodically repeated as the effect fades over time. Gastric stimulators are widely discussed but rarely utilized in practice despite some evidence of efficacy, most commonly in terms of improvement in symptoms such as nausea and vomiting.What about gastric peroral endoscopic myotomy (GPOEM)? Essentially an endoscopic version of surgical pyloromyotomy or pyloroplasty, GPOEM does not improve gastric contractility per se, but it makes the gastric contractions that patients do have more effective and can markedly reduce symptoms. Data supporting the use of GPOEM in patients with gastroparesis has been accumulating rapidly. GPOEM appears to be comparable in outcome to surgical pyloromyotomy/pyloroplasty. GPOEM also appears to be effective as long-term therapy, with 3-year outcome data showing a durable effect. GPOEM has shown efficacy across a wide range of etiologies of gastroparesis as well. Lastly, GPOEM is more cost-effective than Botox injections over the long term.So, why doesn’t everybody with gastroparesis simply get GPOEM? Several explanations exist. Although developed over a decade ago, GPOEM is still only available in specialized centers because it is considered a high-end, advanced endoscopic technique. Many major metropolitan centers may only have one provider able to perform GPOEM. Some rural regions may not even have one GPOEM provider in their entire state. Many patients are not candidates due to comorbidities, heavy tobacco use, or other factors. Another issue is, truth be told, that patients with gastroparesis are often viewed by healthcare providers as difficult to please and undesirable, and consequently patients may have difficulty finding a physician willing to care for them. Many gastroenterologists may be hesitant to learn how to do GPOEM for fear that they become overwhelmed with patients with gastroparesis. Many providers would simply rather treat more straightforward conditions. As someone who started performing GPOEM in large numbers several years ago and has done several hundred of these procedures, I can tell you a few things. First, the procedure is undeniably effective. Whether you are routinely using the Gastroparesis Cardinal Symptom Index score to objectively assess your patients or simply talking to them before and after the procedure and assessing their response, you cannot deny that the changes patients experience are often dramatic. Patients reliant on feeding tubes are frequently able to discontinue their use and have them removed. Patients on promotility agents can often stop taking them. Patients on total parenteral nutrition can often resume oral intake. Patients who were formally subsisting on liquids only can often advance their diet to an extent that they would have previously thought impossible. I have had many spouses regale me, often through tears, of what it meant to them to see their partner eat a meal at the table with the family for the first time in years and not be sick afterward (“She ate a sandwich!”). That being said, it is paramount to emphasize realistic expectations when treating patients with gastroparesis. As the saying goes, “It’s an endoscope, not a magic wand!” No matter what option patients select, they will still have gastroparesis and not all treatments work in all patients, so they cannot expect miracles. I always tell my gastroparesis patients: The odds that I can cure you are low, but the odds that I can help you are high.Dr Adler is director of the Center for Advanced Therapeutic Endoscopy (CATE) at Porter Adventist Hospital in Denver, Colorado, and director of the Advanced Endoscopy Fellowship at CATE.