GPOEM and/or POP - What is it and How Does it Help?

GPOEM is a new procedure, created at Emory, in order to help normalize gastric emptying. The information about GPOEM can be found below. I'm not entirely familiar with it yet but it seems like a promising treatment. It is also called "POP" surgery. I guess we will see.

"SAN DIEGO — Gastric peroral endoscopic myotomy (G-POEM) can be used to effectively treat the vast majority of patients with gastroparesis refractory to conventional therapy, two new studies show.

Gastroparesis is a chronic, often disabling, disorder that affects about 4% of the population. It can be a complication of diabetes or surgery, but in about one-third of cases, it is idiopathic. Medical treatment frequently fails.

G-POEM is modeled on the natural orifice endoscopic POEM for the treatment of achalasia. The procedural principles of the two techniques — such as mucosal entry, tunneling, myotomy (including pyloromyotomy), and closure of mucosal entry — are similar.

Results from the first study, on 30 patients with gastroparesis treated with G-POEM, were presented here at Digestive Disease Week 2016 by Mouen Khashab, MD, from the Johns Hopkins Hospital in Baltimore.

All 30 patients had symptoms refractory to medical therapy, including onabotulinumtoxinA (Botox) injection and transpyloric stenting. Nausea and vomiting affected 25 (83%) patients, weight loss affected 27 (90%) patients (average loss, 10% of body weight), and delayed gastric emptying affected 11 (37%) patients.




Response Rate Exceeds 85% in Two Early Studies

For the 30 patients, mean duration of the G-POEM procedure was 72 minutes, and mean hospital stay was 3.3 days.

At mean follow-up of 5.5 months (range, 3.0 - 30.0 months), 26 (86%) patients had achieved a clinical response, defined as improvement in gastroparetic symptoms without recurrent hospitalization. Of the four patients who did not respond to G-POEM, two had diabetes, one had gastroparesis of idiopathic origin, and one was postsurgical.

"These responses were sustained, and there were no further hospitalizations," Dr Khashab reported.

Of the 17 patients who underwent repeat gastroesophageal scintigraphy, eight (47%) showed normalization of gastric emptying and six (35%) showed improvement.

'G-POEM concomitantly results in normalization of gastric emptying in a significant proportion of treated patients,' he said.

Adverse events occurred in two (6.7%) patients: one developed pneumoperitoneum and the other developed prepyloric ulcer.

'We had two minor complications, but these 30 procedures were performed by very experienced endoscopists at tertiary centers,' he explained. 'G-POEM is more technically challenging than esophageal POEM, as the location is more distal.'

On the basis of these 'amazing results,' Dr Khashab told Medscape Medical News, 'we are starting a multicenter prospective trial in the United States, South America, and Asia, recruiting about 50 patients. This will be definitive.'"

Source: http://www.medscape.com/viewarticle/863847

"G-POEM Shows Promise for Relieving Gastroparesis Symptoms, Improving QOL (Quality of Life)

LAS VEGAS — The minimally invasive procedure called gastric per oral endoscopic pyloromyotomy, or G-POEM, demonstrated promising short-term outcomes for patients with gastroparesis, according to retrospective data presented at ACG 2016.

'We showed that ... G-POEM is a feasible approach for treating gastroparesis,' Sunil Dacha, MD, from Emory University School of Medicine, said during his presentation. 'There was significant improvement in symptoms in most patients, and we showed an improvement in [Gastroparesis Cardinal Score Index (GCSI)], reduced gastric retention percentages on 4-hour [gastric emptying study (GES)] and significant improvements in quality of life domains.'


Dacha and colleagues reviewed data on 10 patients with refractory gastroparesis who underwent G-POEM (mean age, 47.3 years). Four patients had diabetic gastroparesis, four idiopathic, one post-infectious and one post-surgical. Eight were women, four were black and six were white.


The procedure was successful in all patients with no adverse events, a mean procedural duration of 47.7 minutes, a mean myotomy length of 2.94 cm, and a mean length of stay of 2.5 days.

After a mean follow-up of 4.6 months, eight of the patients achieved clinical success, defined by reduced GCSI scores and no recurrent hospitalization.

Mean GCSI scores dropped from 30.1 to 12.8 in these patients (P = .0001), and GES normalized in five patients and improved in two. Additionally, mean 4-hour gastric retention on GES dropped from 62.5% to 25.4% (P = .009) after the procedure.

Several quality of life domains on the SF-36 questionnaire also improved significantly at follow-up, including bodily pain, general health, vitality, social functioning and mental health.

One of the patients did not respond and was hospitalized for nausea and vomiting 15 days after the procedure, and another did not experience improvement of symptoms.

In the future, 'we need to identify the exact subset of patients that benefit from G-POEM, and we need to standardize the work-up and the procedural techniques as there is no uniform agreement on the procedural techniques at this point,' Dacha said. 'We need to standardize measurement of outcomes, ... long-term outcomes data are needed,' and especially important is 'training the future generation of endoscopists for G-POEM, which is essentially endoscopic surgery rather than an endoscopic procedure.' – by Adam Leitenberger

Reference:

Dacha S, et al. Abstract #2. Presented at: American College of Gastroenterology Annual Scientific Meeting; Oct. 17-19, 2016; Las Vegas, NV."

Source: http://www.healio.com/gastroenterology/motility/news/online/%7B8bbd20d4-ea2d-4dbb-adb9-1c45bc26f77f%7D/g-poem-shows-promise-for-relieving-gastroparesis-symptoms-improving-qol

Minimally Invasive Procedure for Gastroparesis Shows Promising Results

"A minimally invasive procedure at Emory University Hospital is showing promise in patients with gastroparesis, a digestive disorder in which the stomach does not empty food in a normal manner. The results of two small Emory studies were presented recently at the American College of Gastroenterology (ACG) in Las Vegas, where the researchers accepted the 2016 ACG Governor’s Award for Excellence in Clinical Research and the ACG Presidential Poster Award.

Gastroparesis occurs in diabetic patients and other patients with no underlying causes, where the muscles of the stomach and intestines do not properly function. Food then moves slowly or stops moving through the digestive tract.

In one study, Emory researchers performed a retrospective review of data in 10 patients who underwent gastric peroral endoscopic pyloromyotomy or G-POEM for gastroparesis. G-POEM involves guiding a small knife through an endoscope into the submucosal tunnel. Once there, an incision is made in the pyloric ring muscle to release the tightness of that muscle and normalize gastric emptying.

'In these 10 patients, clinical success was defined by improvement of symptoms measured with a decrease in the Gastroparesis Cardinal Score Index (GCSI) and no recurrent hospitalization,' says Sunil Dacha, MD, assistant professor of medicine in the Division of Digestive Diseases, Emory University School of Medicine, and a former advanced endoscopic fellow with Qiang Cai, MD, professor of medicine in the Division of Digestive Diseases at Emory, who is an expert in the minimally invasive procedure. 'We found G-POEM was clinically successful in eight of the 10 patients (80 percent) with a decrease in mean GCSI from 30.1 prior to the procedure to 12.8 at follow-up.'

Gastric emptying studies were obtained on seven of the 10 patients following G-POEM. Results showed gastric emptying had normalized in five patients and improvements were noted in two other patients. Mean four-hour gastric retention decreased from 62.5 percent to 25.4 percent after G-POEM, indicating the stomach emptied much faster at four hours after a meal. A follow-up questionnaire also highlighted significant improvement in quality of life in several areas.

One patient in the study had no response and required hospitalization 15 days after G-POEM and another patient showed no improvement in symptoms.

A second study, presented at the ACG by Abhinav Koul, MD, a former Emory medical resident who worked with Cai, detailed three patients with gastroparesis who had failed gastric electrical stimulation, but showed improvement following G-POEM. Electrical stimulation of the gastric nerves by a small implantable device is one treatment option for patients with gastroparesis. In this retrospective study, Emory researchers determined G-POEM can be performed safely as a salvage therapy for patients with gastroparesis who failed treatment with a gastric stimulator.

The study also found G-POEM improved symptoms (mean GCSI decreased by an average of 64 percent from 27 to 10) as well as gastric emptying (60.6 percent to 18.3 percent mean average) in these patients. However, more data is needed to further define the role of G-POEM in this challenging patient population. Koul is now a clinical assistant professor at the Medical College of Georgia-UGA Medical Partnership at Athens Regional Medical Center.

'G-POEM is showing some positive results as an additional therapeutic modality for patients with gastroparesis who suffer with delayed gastric emptying,' says Cai, who also serves as the director of the Advanced Endoscopy Fellowship at Emory. 'We are only one of a few centers in the U.S. offering this specialized procedure.'

In 2012, Cai started the POEM procedure at Emory University Hospital for patients with achalasia, a disorder of the esophagus that causes swallowing difficulties. He then developed the G-POEM program at the hospital, in hopes of finding alternative treatments for patients with gastroparesis."

Source: http://news.emory.edu/stories/2016/10/cai_dacha_gpoem_for_gastroparesis/

Ultrasound Today - Update on my Personal Struggle

I went to Emory for an ultrasound today at the bequest of my Doctor, for my liver. My liver enzymes have been quite high over the past two years now, and no one has discovered why. When I was first diagnosed with Gastroparesis, the theory was that it was because of stones in my liver. They went in and relaxed my sphincter that doles out bile from my liver, removing a "gravely type sludge," as my doctor put it, from where my gallbladder used to be. The Doctor at Emory told me that with Gastroparesis, there should be no pain. Every time a doctor tells me that, I want to laugh in their face and correct them. Tell them that if they had Gastroparesis, they'd feel differently. Everyone I've talked to that has been diagnosed, even with mild Gastroparesis, has dealt with some sort of pain.

So, a good friend and fraternity brother of mine, picked me up and took me to Emory. I was led into the room with the ultrasound machine. I laid down on the table and lifted up my shirt for the procedure. I was happy to say that there were butterflies painted on the ceiling tiles so that I actually had something to focus on. The lab tech started and pressed the probe down on such tender parts that had been giving me such pain. I bit my lip and squeezed my friend's hand because it hurt so much. I had an emesis bag, just in case I needed it.

I looked away because it hurt too much. My friend said the lab tech was making awful faces and she had a feeling that they found something wrong. Of course, the lab techs won't tell you anything - it's a liability factor. She had me turn to my side and looked at my kidneys as well. Then, we were done. The procedure probably took half an hour of thorough investigating with a very painful probe. Ultrasounds normally aren't painful, but I've been experiencing pain in my upper right side. I didn't start retching until we were in the car. Anytime a doctor or someone presses on my upper right side and my stomach - I vomit. Thankfully, it waited until I was home. I fell over on the toilet and vomited up what I tried to eat for lunch today - considering I haven't eaten in a while. I was thankful I had something to vomit up besides bile. I realize how bad that sounds but I've been throwing up nothing but bile for days, my throat welcomed some relief.

I've been coughing a lot because my throat is irritated from vomiting. The doctor will receive my ultrasound report in a few days and call me with the results. I'm nervous because my liver enzymes are high and I don't know what that means. I've never been so nervous. Will I have to have more surgery? Will someone take me seriously? I need some help. What I'm doing right now is not living - it's awful.

The only solace in the past few days have been my husband, who is a wonderful and caring man, and reading outside in the sunshine.

I am anxiously awaiting the results and to wonder where to go from here.

In the meantime, I've made an appointment with a psychologist because I am determined to prove to these doctors that the anxiety didn't get worse until after I had Gastroparesis. The doctor I saw before, not at Emory, at Mayo, told me that this was all in my head an all anxiety related. I want a doctor to evaluate that and tell me that it's not true. I just need someone to listen to me. I can't make up vomiting or pain like this. It's immobilizing. My friends and family see me suffer and I barely recognize my own reflection in the mirror because of my hallowed out, pale face, and the dark circles under my eyes. I think it will be good to have someone to speak with anyway, but I want someone to validate me and say that my GP is legitimate and that it's not caused by anxiety. That made me angry more than anything when the Mayo doctor told me that. I think he only did so because he correctly assumed that I'd be a complicated case, and he didn't want to deal with me personally.

I'm keeping track of my symptoms in a written journal, along with how I feel. A GP friend of mine told me about an app available called MySymptom Tracker. It's $3 in the Google Play store but worth it. So, I track my vomiting, medications, mood, etc on my phone as well. You can download it and bring it in with you to your doctor, which I find useful. I document everything. It's a good habit to have.

I feel like I'm preparing for battle. I'm going to fight to be healthy again.

From August Until Now

As of right now, my medication list is extremely long.

I'm taking:

Linzess 290mg - once daily
Phenergan 25mg - three times daily
Zofran 8mg - three times daily
Vicodin 10/325 - four times daily (for my lower back - I keep straining it vomiting and may have shifted the spinal cord stimulator out of place)
Xanax 0.5mg - four times daily
Celexa 20mg - once daily
Implanon - birth control I need to call and get replaced
Restoril 15mg - twice at bedtime for sleep
Trazadpne 50mg - three times daily
Protonix 40mg - twice daily
B-12 Injections

I feel like this when it's time to take my medications:

I saw my doctor in Augusta about what to do since none of the doctors here are listening to me. He was going to recommend a great GI doctor to me but I guess he got side tracked. I'll have to call him and find out the person. None of the ones up here seem to care and they've managed to convince my husband that this is all in my head due to anxiety. My Augusta doctor wanted me to go to the ER but I refused. Instead, he gave me medications and my sister took me to her house and made my comfortable.

I've been managing to eat small amounts here and there. Yogurt and maybe a bite or two of bagel. Nothing substantial.

I started my period on the 23rd - and it made my GP TEN TIMES WORSE! I'm not the only one who suffers this way. I wonder what the connection is between GP and hormones? I want to bookmark this to come back to it and research it later.

The doctor at Emory yesterday wants me to get an ultrasound for my liver. She's worried about my high liver enzymes. She switched around my medication and wants to see if that helps. I wanted to scream at her that my medicine has been switched around before with no relief! Ugh! But I understand conservative measures first. It just SUCKS. I have to follow up with her in six weeks.

I woke up yesterday and vomited directly into a trashcan. I wonder why I couldn't do that in front of the doctor? *sigh*

Oh well.

But, I have a new phone now so I'm easier to get in touch with. My old phone stopped charging.

Hang in there and keep fighting. I'm working on an article coming up about stress relief and how to manage stress. I just wanted to check in.

The top picture is before I ate, the bottom picture is after I ate.