Treatment of Gastroparesis (G-POEM)

Gastroparesis (or gastric paralysis) is characterized by delayed stomach emptying, meaning the stomach takes a long time to empty its contents. Sometimes, when food is not properly emptied, solid masses of old food can form. These masses can block the stomach and lead to symptoms such as nausea, vomiting, and even gastric obstruction, which may prevent food from passing into the small intestine.

Gastric Per Oral Endoscopic Myotomy (G-POEM) with Dr. Shaimaa El Kholy, Associate Professor of Advanced Interventional Gastrointestinal Endoscopy (ESD & Third Space Endoscopy), is a non-surgical procedure designed to treat individuals suffering from chronic gastroparesis.

G-POEM is performed endoscopically without surgery, meaning it does not require incisions in the skin. During the procedure, the muscle ring that controls the flow of stomach contents into the small intestine is released to allow food to pass freely.

• Early feeling of fullness.

• Bloating.

• Nausea.

• Loss of appetite.

• Vomiting.

• Abdominal pain.

• Weight loss.

An endoscope is a thin, flexible tube that Dr. Shaimaa El Kholy passes through the mouth into the intestines. The upper endoscopy is performed to visualize the esophagus and stomach.

Barium coats the esophagus and gastrointestinal tract when swallowed, making it easier to detect abnormalities and delayed gastric emptying during X-rays.

The patient is given a meal or drink with a radioactive marker that can be seen by a scanner. The purpose of this test is to track the marked food as it moves through the gastrointestinal tract. This is the most commonly used test to confirm gastroparesis. Unlike other diagnostic procedures that require fasting, this test requires the patient to consume the special meal just before the test.

This test evaluates the muscles involved in digestion by measuring electrical and muscular activity in the stomach during fasting and digestion.

The wireless motility study assesses the time it takes for the stomach to empty. This procedure is generally simpler and less invasive than other diagnostic methods.

Gastric Per Oral Endoscopic Myotomy (G-POEM) is a minimally invasive procedure to alleviate symptoms of gastroparesis. In patients with gastroparesis, the gastric outlet muscle between the stomach and small intestine (pyloric sphincter) is unusually tight, preventing complete emptying of stomach contents into the intestines.

During the G-POEM procedure, an endoscope (a narrow tube equipped with a camera) is inserted through the mouth to incise the pyloric muscle. This permanently relaxes the muscle, allowing food to empty freely. G-POEM is a less invasive alternative to surgical procedures that aim to dilate the pyloric muscle.

G-POEM works similarly to the original POEM procedure performed on the valve between the esophagus and stomach to treat swallowing difficulties or achalasia. The success of POEM in treating dysphagia, which is caused by a dysfunction of the esophageal-stomach valve, led to the modification of the procedure for treating gastroparesis.

G-POEM is an effective treatment for patients with gastroparesis unresponsive to treatment and who:

1. Have undergone an upper endoscopy to ensure there is no mechanical obstruction at the stomach exit.

2. Have undergone a gastric emptying study to confirm delayed gastric emptying, preferably with retention > 20% at 4 hours.

3. Experience moderate to severe symptoms of nausea and vomiting.

4. Suffer from gastroparesis due to diabetes, previous surgery, or unknown causes.

5. Have failed electrical stimulation therapy for the stomach and Botox injections.

6. Have a stent placed in the pyloric muscle to keep it open, but since stents often move, it is not a permanent solution; G-POEM offers long-term relief from gastroparesis.

 

• Individuals who have had major gastrointestinal surgery in the past that put the gastrointestinal tract at risk.

• Pregnant women.

• Individuals with severe bleeding disorders.

Dr. Shaimaa El Kholy, Associate Professor of Advanced Interventional Gastrointestinal Endoscopy (ESD & Third Space Endoscopy), Faculty of Medicine, Cairo University, provides specific instructions to follow before G-POEM, which may include following a liquid diet for several days before the scheduled procedure. If the patient takes certain medications that may interfere with the procedure, Dr. Shaimaa El Kholy will advise him to stop taking them temporarily if necessary.

1. A cannula is inserted into a vein to administer fluids, anesthesia, and antibiotics. An airway tube may be placed in the trachea to assist with breathing under general anesthesia.

2. Dr. Shaimaa El Kholy passes the endoscope through the mouth and directs it to the stomach, aided by detailed and precise images displayed on a monitor.

3. Carbon dioxide gas is injected through the oral cavity to provide better visibility of the internal structures through the endoscope.

4. Dr. Shaimaa El Kholy then introduces tools through the endoscope to make a small incision in the inner lining of the stomach near the entrance to the small intestine.

5. A fluid solution is injected into this opening, and the endoscope separates the layers of the gastrointestinal wall from the muscles.

6. A small tunnel-like pathway is created beneath the stomach lining leading to the tightened pyloric muscle.

7. When the endoscope reaches the opening between the stomach and the duodenum, Dr. Shaimaa El Kholy incises the pyloric muscle.

8. Dr. Shaimaa El Kholy closes the incision in the stomach lining with high-quality endoscopic clips to prevent any holes and then withdraws the endoscope.

Upon completion of the procedure, the patient recovers from anesthesia in the recovery room. The patient begins a full liquid diet to protect the stomach lining during healing. This diet then progresses to soft foods after the first three days, after which Dr. Shaimaa's medical team will monitor the patient and explain instructions on when to resume a normal diet.

The patient may need to return for testing and follow-up to assess the success of the G-POEM procedure. Dr. Shaimaa El Kholy will conduct a gastric emptying study to determine how quickly food passes into the small intestine. A barium contrast radiography will also ensure the surgical area is safe. Dr. Shaimaa El Kholy may use an endoscope to check how the tissue is healing.

G-POEM is effective in relieving symptoms of gastroparesis. Other advantages include:

• No external skin incisions.

• No external scars.

• Safe.

• Well-tolerated.

• Shorter recovery time compared to surgery.

Thus, third-space endoscopy provides the optimal and definitive solution for gastroparesis by G-POEM with the expertise of Dr. Shaimaa El Kholy, Associate Professor of Advanced Interventional Gastrointestinal Endoscopy (ESD & Third Space Endoscopy), one of the pioneers in this field in Egypt and the Arab world.