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Nutritional Support in Gastroparesis: Percutaneous Endoscopic Gastrostomy with Jejunal Extension: The Ultimate Solution? A Retrospective Analysis

| Gastroenterology
Authors:
*Denise Strijbos,1,2 Daniel Keszthelyi,1 Ad A.M. Masclee,1
Disclosure:

The authors have declared no conflicts of interest.

Citation
EMJ Gastroenterol. ;6[1]:41-42. Abstract Review No. AR2.

Each article is made available under the terms of the .

Gastroparesis is characterised by delayed gastric emptying in the absence of mechanical obstruction.1 In our tertiary referral centre, patients are treated with a stepwise approach, starting with dietary and lifestyle advice, and prokinetics. When these initial measures fail, in the presence of malnutrition, patients are offered 3 months of nasoduodenal tube feeding with ‘gastric rest’ and eventually placement of a percutaneous endoscopic gastrostomy with jejunal extension (PEG-J). In our study, presented at UEG Week 2017, we aimed to evaluate the effect of nutritional treatment entities in patients with gastroparesis on weight gain and symptoms.

Retrospectively collected data of all referred gastroparesis patients between 2008 and 2016 were reviewed. A total of 86 gastroparesis patients, 71% of which were female, between the age of 20 and 87 years (mean age: 55.81 years) were analysed. Aetiologies were idiopathic (37.2%), diabetes (26.7%), post-surgical (26.7%), and other (9.4%). Of the 86 patients, 50 had adequate responses to dietary advice and prokinetics, while the other 36 were treated with 3 months of gastric rest. The mean weight gain in symptom responders was 3.6% (2.5 kg; p=0.018) and 3.3% (2.1 kg; p=0.027) in non-responders.

After 3 months of gastric rest, the 19 non-responders continued treatment with enteral feeding through PEG-J. A significant weight gain was seen in symptom responders (n=14, 74%) to PEG-J (8.3%, 5.04 kg; p=0.016) within 6 months after PEG-J placement. Four patients did not show symptom response to PEG-J treatment; however, the patients did gain weight (mean weight gain: 6 kg, 8.1%; p=0.089). The outcome for 1 patient was missing. On long-term follow-up, only 3 patients (16.7%) were able to resume complete oral intake and the PEG-J was removed after 11 months. In 83.3% of patients, the PEG-J was still in use, with a mean treatment time of 962 days. The most frequent complication associated with the treatment was luxation of the jejunal extension to the stomach, which occurred in 32% of patients.

Regarding enteral feeding in gastroparesis, guidelines indicate a trial with enteral feeding before placement of a long-term device to see whether or not enteral feeding is tolerated.2 Some patients may find the 3-month period of nasoduodenal feeding long, but the length of such intervention remains the topic of further investigation. Historically, surgical jejunostomies have often been used for long-term nutritional support in gastroparesis, but this technique is associated with a lower placement success rate of 68%,3,4 and a relatively high complication rate of 10%,5 hence our preference for the endoscopic placement approach.

An interesting phenomenon we observed was that, in general, all types of nutritional support measures led to an increase in weight but not always to a decrease in symptom severity. We have not been able to discriminate a group that is unlikely to show a symptom response to enteral feeding, either with demographic or scintigraphic parameters. The retrospective nature of the study did not allow assessment of other factors, including psychological influences, but we postulate that visceral hypersensitivity plays a paramount role in patients who do not show symptom response. We therefore believe that systematic assessment of mood and anxiety disorders should be an integral element of the diagnostic work-up and therapeutic plan in patients with gastroparesis.

References
Shin AS, Camilleri M. Diagnostic assessment of diabetic gastroparesis. Diabetes. 2013;62(8):2667-73. Camilleri M et al. Clinical guideline: Management of gastroparesis. Am J Gastroenterol. 2013;108(1):18-38. Moran GW, Fisher NC. Direct percutaneous endoscopic jejunostomy: High completion rates with selective use of a long drainage access needle. Diagn Ther Endosc. 2009;2009:520879. McCarty TR, Rustagi T. Endoscopic treatment of gastroparesis. World J Gastroenterol. 2015;21(22):6842-9. Maple JT et al. Direct percutaneous endoscopic jejunostomy: Outcomes in 307 consecutive attempts. Am J Gastroenterol. 2005;100(12):2681-8.