G-POEM Options Equally Effective for Gastroparesis Symptom Relief
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Summary
- Miller School researchers showed that both forms of a special, minimally invasive procedure for gastroparesis are equally effective.
- Gastric peroral endoscopic myotomies are performed either along the greater curvature or lesser curvature of the stomach.
- Miller School digestive and liver diseases experts said the study could encourage physicians to train in both approaches.
Patients with gastroparesis have reason to cheer.
A meta-analysis led by researchers at the University of Miami Miller School of Medicine and published in Gastrointestinal Endoscopy reveals that both forms of a special, minimally invasive procedure aimed at ameliorating the condition are equally effective.
The intervention, known as gastric peroral endoscopic myotomy (G-POEM), can be performed from the greater curvature (the stomach’s outer curve) or the lesser curvature (the inner curve).
“Currently, there is no consensus on which version of G-POEM is more effective,” said senior author Sunil Amin, M.D., associate professor in the Division of Digestive Health and Liver Diseases and director of endoscopy at the Miller School. “Because our investigation reveals that both versions are similarly beneficial, physicians and patients stand to gain from the flexibility of choosing.”
What is gastroparesis?
Gastroparesis is a chronic, blockage-free digestive condition that causes the stomach to empty too slowly. When food is swallowed, stomach muscles contract, breaking the food into smaller pieces and propelling them into the small intestine. For patients with gastroparesis, the muscle contractions slow down, causing delays in digestion and symptoms including nausea, vomiting, feeling full before finishing a meal and stomach pain.
The most common trigger for gastroparesis is type 2 diabetes, followed by previous stomach surgery. Opioid pain relievers, high blood pressure medications, certain antidepressants and allergies are also factors. But in up to half of cases, gastroparesis has no clear cause.
Gastric Peroral Endoscopic Myotomy
Options for treating gastroparesis include medication, botulinum toxin (Botox) injections and surgery. The first two aren’t always effective, benefiting fewer than half of patients. The higher success rate of surgery may be outweighed by the intensity of and recovery period for the process.
G-POEM occupies a middle ground, addressing deficiencies of the other approaches. Success rates can reach 80%, and hospital stays are shorter and recovery faster in comparison to other procedures.
Currently, there is no consensus on which version of G-POEM is more effective. Because our investigation reveals that both versions are similarly beneficial, physicians and patients stand to gain from the flexibility of choosing.
Dr. Sunil Amin
Doctors pass an endoscope through the mouth and into the stomach. They then make a small incision in the stomach lining to access and cut the pyloric muscle. Relaxing this valve enables food to move more freely into the intestines, easing symptoms.
“G-POEM is a game changer for managing patients who suffer from gastroparesis,” said the study’s co-lead author, Rahil Shah, M.D., a digestive health and liver diseases fellow at Miller. “Many of them haven’t improved with standard therapies. Now we are able to offer a minimally invasive procedure to alleviate their symptoms, improving overall quality of life.”
The Two Types of G-POEM
There are two types of G-POEM: one aimed at the greater curvature of the stomach and the other at the lesser curvature. Initially, physicians performed the procedure exclusively along the greater curvature. The lesser curvature approach creates a shorter “tunnel” for the instruments that cut the pyloric muscle. This can reduce the time of the procedure to as little as 15 minutes, compared to a 45-minute average with the greater curvature approach. Less time under anesthesia is generally better for patients. Fewer resources are used as well, reducing costs.
However, the shorter tunnel is also narrower, resulting in less space for maneuvering instruments. The lesser curvature has higher vascular density, as well, increasing the risk of bleeding.
The greater curvature approach has been in use longer, so it is buttressed by more clinical data. It is also the technique more physicians have been trained to perform.
Reviewing the G-POEM History
To find out, the Miller School research team carried out a meta-analysis that combines data from smaller studies to look for trends. The team reviewed 16 studies conducted between 2000 and 2023, totaling 621 patients. Of these, 460 underwent the greater curvature approach and 161 the lesser curvature approach.
The findings were clear. The approaches worked equally well for symptom relief. Overall, three-quarters of patients reported significant reductions of symptoms three to six months after the procedure, and 64% at 12 months.
The meta-analysis did find some differences between the two approaches:
• In the short term, patients in the greater curvature group reported slightly better symptom scores.
• Those in the lesser curvature group had fewer mild complications, such as pain or minor bleeding, and shorter hospital stays (1.5 days versus 2.1 days, on average).
“We found that the lesser curvature approach was just as effective in relieving symptoms, but may offer advantages in terms of recovery and safety,” said co-lead author Shyam Vedantam, D.O., digestive health and liver diseases fellow at the Miller School. “While we believe that this is still a procedure that should be personalized to each patient and physician, this can be helpful information going forward.”
The team also looked at results from a gastric emptying study, the standard test for diagnosing gastroparesis. On average, the amount of food remaining in the stomach after four hours fell from 40% to 16% under both versions of G-POEM, representing a 60% improvement.
Implications for Training Physicians
The study asserts the advantage of physicians being trained in both approaches. If a patient has not done as well with one version of G-POEM, they might benefit from the alternative. Also, patients’ physical differences may mean one approach is inherently better than the other.
The meta-analysis highlights the importance of a consensus definition of clinical success. For example, some studies used absolute improvements in symptom scores while others used percentage improvements. Establishing a consensus would ensure apples-to-apples comparisons.
More long-term data on the effectiveness of G-POEM would also help, as most existing studies are limited to less than 24-month timeframes. This is crucial for optimal patient care, especially since some studies show diminishing benefits over time.
“Because of its encouraging signs in alleviating symptoms of gastroparesis, G-POEM will continue gaining in volume, becoming more and more accepted as a treatment option,” said Dr. Amin. “Patients with this devastating condition have good reason for optimism.”
Tags: Department of Medicine, Division of Digestive Health and Liver Diseases, G-POEM, gastroparesis, liver diseases
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