Gastroparesis – too complicated for a simplistic therapeutic approach

I read with great interest the paper by Shen et al. [1] comparing the effect of gastric peroral endoscopic pyloromyotomy (G-POEM) versus gastric electrical stimulation (GES) on refractory gastroparesis and the corresponding editorial by Parkman. I interpret the results of the study [1] as being rather disappointing and do not see evidence for a relationship between intervention-induced improvement of gastric emptying and symptoms for the following reasons:

(i) 45 patients (40 %) had to be excluded, leaving only 66 patients for further study. Of these, 27 patients (40 %) showed recurrence after therapy: 12 patients (30.8 %) in the G-POEM and 15 patients (55.6 %) in the GES group. In addition, over 30 % still needed nutritional support (parenteral nutrition, tube feeding) post-intervention.

(ii) Over 50 % of the patients had idiopathic gastroparesis and a significant proportion a complex symptomatology, because up to 52.2 % took antidepressants and/or chronic analgesics, which are not normally associated with gastroparesis. This opens the study to large placebo effects.

(iii) Data on post-interventional gastric emptying are sparse. Gastric emptying following GES was studied in only one-third of the patients and no information about the correlation between gastric emptying and symptoms or the shift in the individual patient scores post-intervention is presented. This is of importance because numerous studies have failed to find a clinically relevant relationship between gastric emptying and symptomatology [2] [3] [4].

The results of the study do not support the wide application of G-POEM or GES in patients with gastroparesis at this stage. The simplistic therapeutic approach of improving the symptoms of gastroparesis by just accelerating gastric emptying does not respect the complex physiology and pathophysiology of gastrointestinal function. The findings of the study may have been affected by placebo effects and/or alteration of visceral perception, as has been suggested for endoscopic reflux therapy [5]. Placebo-controlled studies in selected subgroups of patients are mandatory.

Publication History

Article published online:
17 December 2020

• References

• 1 Shen S, Luo H, Vachaparambil C. et al. Gastric peroral endoscopic pyloromyotomy versus gastric electrical stimulation in the treatment of refractory gastroparesis: a propensity score-matched analysis of long term outcomes. Endoscopy 2020; 52: 349-358
• 2 Janssen P, Harris MS, Jones M. et al. The relation between symptom improvement and gastric emptying in the treatment of diabetic and idiopathic gastroparesis. Am J Gastroenterol 2013; 108: 1382-1391
• 3 Hasler WL. Gastroparesis: pathogenesis, diagnosis and management. Nat Rev Gastroenterol Hepatol 2011; 8: 438-453
• 4 Levinthal DJ, Bielefeldt K. Systematic review and meta-analysis: gastric electrical stimulation for gastroparesis. Auton Neurosci 2017; 202: 45-55
• 5 Wenzel G, Kuhlbusch R, Heise J. et al. Relief of reflux symptoms after endoscopic gastroplication may be associated with reduced esophageal acid sensitivity: a pilot study. Endoscopy 2005; 37: 236-239