Ravikumar, Naveen Prasad Gopalakrishnan

INTRODUCTION: Options to treat medically refractory gastroparesis are limited. Gastric peroral endoscopic myotomy (G-POEM) is a novel minimally invasive technique in endosurgery that has shown promising results. Data is limited as to its efficacy, safety, predictive factors and its comparability to surgical pyloroplasty. The aim of our study was to synthesize and analyze the clinical outcomes of GPOEM by meta-analysis methods. METHODS: We searched multiple databases from inception through March 2019 to identify studies that reported on G-POEM and surgical pyloroplasty in gastroparesis. Our primary outcome was to analyze the pooled rates of gastroparesis cardinal symptom index (GCSI) score and 4-hr gastric emptying study (GES) results, with G-POEM. Similar outcomes with surgical pyloroplasty was used as a comparator group. RESULTS: 332 and 375 patients underwent G-POEM (11studies) and pyloroplasty (7studies), respectively. The pooled rate of clinical success, based on the GCSI score, with G-POEM was 75.8% (95% CI 68.1-82.1, I 2 = 50) and with pyloroplasty was 77.3% (95% CI 66.4-85.4, I 2 = 0), with no significance, P = 0.81. The pooled rate of clinical success, based on the 4-hour GES results, with GPOEM was 85.1% (95% CI 68.9-93.7, I 2 = 74) and with pyloroplasty was 84% (95% CI 64.4-93.8, I 2 = 81), with no significance, P = 0.91. The pooled rate of mean pre-G-POEM GCSI score was 3.4 (95% CI 3.1-3.7, I 2 = 89) and post-G-POEM GCSI score was 1.8 (95% CI 1.4-2.1, I 2 = 89), with statistical significance ( P = 0.001). The pooled pre-G-POEM 4-hr GES was 49.9% (95% CI 41.6-58.3, I 2 = 94) and post-G-POEM 4-hr GES was 20.6% (95% CI 12.3-28.8, I 2 = 77), with statistical significance ( P = 0.001). The pre and post pyloroplasty 4-hr GES results were 36% (95% CI 32.7-39.3, I 2 = 88) and 3.9% (95% CI 2.3-5.5, I 2 = 43), respectively ( P = 0.001). The pre and post pyloroplasty GCSI score was not analyzed due to paucity in data. The overall adverse events were comparable (11%, 5.9-19.8, I 2 = 66 vs 11.4%, 5-24, I 2 = 69, P = 0.95). 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 with comparable outcomes to pyloroplasty. Idiopathic gastroparesis, prior treatment with botulinum injection and gastric stimulator appear to have positive predictive effects on the 4-hr GES results after G-POEM.

INTRODUCTION: Surgical gastroenterostomy has been the traditional approach to manage malignant gastric outlet obstruction (GOO). With advances in Endoscopic Ultrasound (EUS) technology and availability of dedicated devices and stents for EUS scopes, EUS guided gastroenterostomy (GE) is emerging as an alternative to surgical gastroenterostomy. Recently studies have been published comparing the outcomes between these two approaches. We performed a systematic review and meta-analysis of studies that compare the outcomes between the two approaches (EUS-GE vs Surgical GE). METHODS: We performed a systematic search of multiple databases through May 2019 to identify studies that compared outcomes of EUS-GE vs surgical GE in management of malignant gastric outlet obstruction. Pooled odds ratios (OR) of technical success, clinical success and adverse events between EUS-GE and surgical GE groups were calculated. RESULTS: Three comparative studies with a total of 171 patients; were included in the analysis. The pooled OR for technical success of EUS-GE in comparison to surgical GE was 0.16 (95% CI: 0.03-0.86; P = 0.033; I 2 = 2%). The pooled OR for clinical success (EUS-GE vs surgical GE) was 0.98 (95% CI: 0.13-7.48; P = 0.984; I 2 = 25%) The pooled OR for overall adverse events (EUS-GE vs surgical GE) was 0.35 (95% CI: 0.15-0.81; P = 0.014, I 2 = 0%). There was minimal heterogeneity in the analysis. CONCLUSION: While EUS-GE is associated with similar rates of clinical success compared to surgical GE, the rate of overall adverse events is statistically lower. Hence in centers with expertise in EUS, EUS-GE could be considered as an effective alternate option.

INTRODUCTION: Endoscopic ultrasound (EUS) guided gastroenterostomy (GE) is emerging as an alternative to enteral stenting and surgical GE for management of malignant gastric outlet obstruction (GOO). With advances in EUS technology and availability of dedicated devices/stents for EUS scopes, the use of EUS-GE is expected to increase in the future. We performed a systematic review and meta-analysis to estimate the success rate and adverse events associated with EUS-GE. METHODS: We conducted a comprehensive search of multiple electronic databases and conference proceedings including PubMed, EMBASE, and Web of Science databases (from inception through May 2019) to identify studies that reported success rate and adverse events of EUS-GE. The primary outcome was to estimate the pooled rates of technical and clinical success of EUS-GE. The secondary outcome was to estimate the rate of adverse events. RESULTS: 9 studies with a total of 268 patients were included. The pooled rate of technical success of EUS-GE was 91.7 % (95% CI 87.5 – 94.5; I2 = 0). The pooled rate of clinical success of EUS-GJ was 87.8% (95% CI 83.1 – 91.3; I 2 = 0). The pooled rate of overall adverse events was 12.6% (95% CI 9.0- 17.6; I 2 = 0). The pooled rate of individual adverse events – perforation, bleeding, peritonitis and stent migration / misdeployment were 2% (95% CI 0.7 – 5.1), 3.2% (95% CI 1.5 – 6.5), 2.6% (95% CI 1.1-6.1) and 8.9 % (95% CI 4.3-17.5) respectively.The rate of surgical intervention for adverse events was 2%. CONCLUSION: While the rates of technical success (92%) and clinical success (88%) of EUS-GJ is promising, the risk of adverse events is considerable at 12.6%, with stent misdeployment (9%) being the most common adverse event. Hence, EUS-GJ should be performed at tertiary referral centers in a multidisciplinary (surgery, oncology, gastroenterology) team-based approach.