Response to botulinum toxin may predict response to peroral pyloromyotomy in patients with gastroparesis

Abstract

Background Patients with gastroparesis who have undergone prior intrapyloric botulinum toxin injection (BTI) may seek an opinion regarding peroral pyloromyotomy (POP). There are only two small reports assessing the role of BTI as a predictor for successful treatment with POP.

Methods We performed a retrospective cohort study to assess whether symptomatic improvement after BTI predicts a response to POP. We included 119 patients who had undergone both BTI and POP at Cleveland Clinic Ohio or Cleveland Clinic Florida from January 2016 to September 2019.

Results 65.5 % of patients had symptomatic improvement after BTI. Gastroparesis Cardinal Symptom Index (GCSI) scores were available for 74 patients, with 64 % achieving a response to POP, defined as a decrease in mean GCSI ≥ 1. In multivariable analysis, response to BTI (odds ratio [OR] 7.7 [95 %CI 2.2–26.1]) and higher pre-POP GCSI score (OR 2.3 [95 %CI 1.2–4.6]) were independent predictors of response to POP.

Conclusions Clinical improvement after BTI is a predictor of response to POP in patients with gastroparesis. This information may aid in improving patient selection for POP.

Publication History

Received: 20 February 2022

Accepted after revision: 23 November 2022

Accepted Manuscript online:
23 November 2022

Article published online:
10 February 2023

• References

• 1 Grover M, Farrugia G, Stanghellini V. Gastroparesis: a turning point in understanding and treatment. Gut 2019; 68: 2238-2250
• 2 Liu N, Abell T. Gastroparesis updates on pathogenesis and management. Gut Liver 2017; 11: 579-589
• 3 Khashab MA, Stein E, Clarke JO. et al. Gastric peroral endoscopic myotomy for refractory gastroparesis: first human endoscopic pyloromyotomy (with video). Gastrointest Endosc 2013; 78: 764-768
• 4 Dacha S, Mekaroonkamol P, Li L. et al. Outcomes and quality-of-life assessment after gastric per-oral endoscopic pyloromyotomy (with video). Gastrointest Endosc 2017; 86: 282-289
• 5 Ezzeddine D, Jit R, Katz N. et al. Pyloric injection of botulinum toxin for treatment of diabetic gastroparesis. Gastrointest Endosc 2002; 55: 920-923
• 6 Miller LS, Szych GA, Kantor SB. et al. Treatment of idiopathic gastroparesis with injection of botulinum toxin into the pyloric sphincter muscle. Am J Gastroenterol 2002; 97: 1653-1660
• 7 Arts J, van Gool S, Caenepeel P. et al. Influence of intrapyloric botulinum toxin injection on gastric emptying and meal-related symptoms in gastroparesis patients. Aliment Pharmacol Ther 2006; 24: 661-667
• 8 Bromer MQ, Friedenberg F, Miller LS. et al. Endoscopic pyloric injection of botulinum toxin A for the treatment of refractory gastroparesis. Gastrointest Endosc 2005; 61: 833-839
• 9 Rameshshanker R, Smith LA, Southern P. et al. Gastroparesis and botulinum toxin. Gut 2011; 60: A105-A106
• 10 Friedenberg FK, Palit A, Parkman HP. et al. Botulinum toxin A for the treatment of delayed gastric emptying. Am J Gastroenterol 2008; 103: 416-423
• 11 Arts 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: 1251-1258
• 12 Ukleja A, Tandon K, Shah K. et al. Endoscopic botox injections in therapy of refractory gastroparesis. World J Gastrointest Endosc 2015; 7: 790-798
• 13 Khoury T, Mizrahi M, Mahamid M. et al. State of the art review with literature summary on gastric peroral endoscopic pyloromyotomy for gastroparesis. J Gastroenterol Hepatol 2018; 33: 1829-1833
• 14 Spadaccini M, Maselli R, Chandrasekar VT. et al. Gastric peroral endoscopic pyloromyotomy for refractory gastroparesis: a systematic review of early outcomes with pooled analysis. Gastrointest Endosc 2020; 91: 746-752
• 15 Uemura KL, Chaves D, Bernardo WM. et al. Peroral endoscopic pyloromyotomy for gastroparesis: a systematic review and meta-analysis. Endosc Int Open 2020; 08: E911-E923
• 16 Meybodi MA, Qumseya BJ, Shakoor D. et al. Efficacy and feasibility of G-POEM in management of patients with refractory gastroparesis: a systematic review and meta-analysis. Endosc Int Open 2019; 07: E322-E329
• 17 Pasricha PJ, Camilleri M, Hasler WL. et al. White Paper AGA: Gastroparesis: clinical and regulatory insights for clinical trials. Clin Gastroenterol Hepatol 2017; 15: 1184-1190
• 18 Abdelfatah MM, Noll A, Kapil N. et al. Long-term outcome of gastric per-oral endoscopic pyloromyotomy in treatment of gastroparesis. Clin Gastroenterol Hepatol 2021; 19: 816-824
• 19 Annese V, Bassotti G, Coccia G. et al. A multicentre randomised study of intrasphincteric botulinum toxin in patients with oesophageal achalasia. GISMAD Achalasia Study Group. Gut 2000; 46: 597-600
• 20 D’Onofrio V, Annese V, Miletto P. et al. Long-term follow-up of achalasic patients treated with botulinum toxin. Dis Esophagus 2000; 13: 96-101
• 21 Malik Z, Kataria R, Modayil R. et al. Gastric per oral endoscopic myotomy (G-POEM) for the treatment of refractory gastroparesis: early experience. Dig Dis Sci 2018; 63: 2405-2412
• 22 Gregor L, Wo J, DeWitt J. et al. Gastric peroral endoscopic myotomy for the treatment of refractory gastroparesis: a prospective single-center experience with mid-term follow-up (with video). Gastrointest Endosc 2021; 94: 35-44
• 23 Lee AA, Hasler WL. G-POEM for gastroparesis: is there pressure to go with the flow?. Dig Dis Sci 2018; 63: 2165-2167
• 24 Vosoughi K, Ichkhanian Y, Benias P. et al. Gastric per-oral endoscopic myotomy (G-POEM) for refractory gastroparesis: results from an international prospective trial. Gut 2022; 71: 25-33
• 25 Bapaye A, Dubale NA. Gastric per-oral endoscopic myotomy: indications, technique, outcomes, and future directions. Int J Gastrointest Interv 2020; 9: 72-77
• 26 Xu J, Chen T, Elkholy S. et al. Gastric peroral endoscopic myotomy (G-POEM) as a treatment for refractory gastroparesis: long-term outcomes. Can J Gastroenterol Hepatol 2018; 2018: 6409698
• 27 Rodriguez JH, Haskins IN, Strong AT. et al. Per oral endoscopic pyloromyotomy for refractory gastroparesis: initial results from a single institution. Surg Endosc 2017; 31: 5381-5388
• 28 Mohan BP, Chandan S, Jha LK. 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 2020; 34: 3352-3367
• 29 Weusten BLAM, Barret M, Bredenoord AJ. et al. Endoscopic management of gastrointestinal motility disorders – part 1: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2020; 52: 498-515
• 30 Orenstein SB, Raigani S, Wu YV. et al. Peroral endoscopic myotomy (POEM) leads to similar results in patients with and without prior endoscopic or surgical therapy. Surg Endosc 2015; 29: 1064-1070
• 31 Sharata A, Kurian AA, Dunst CM. et al. Peroral endoscopic myotomy (POEM) is safe and effective in the setting of prior endoscopic intervention. J Gastrointest Surg 2013; 17: 1188-1192
• 32 Zhang H, Zhang J, Jiang A. et al. Gastric peroral endoscopic myotomy for gastroparesis: a systematic review of efficacy and safety. Gastroenterol Hepatol 2019; 42: 413-422
• 33 Gonzalez J-M, Lestelle V, Benezech A. et al. Gastric per-oral endoscopic myotomy with antropyloromyotomy in the treatment of refractory gastroparesis: clinical experience with follow-up and scintigraphic evaluation (with video). Gastrointest Endosc 2017; 85: 132-139
• 34 Kahaleh M, Gonzalez J-M, Xu M-M. et al. Gastric peroral endoscopic myotomy for the treatment of refractory gastroparesis: a multicenter international experience. Endoscopy 2018; 50: 1053-1058