Johns Hopkins GI doctors use endoscopy to place transpyloric stent

July 03, 2013

Physicians at Johns Hopkins say they are encouraged by early results in three patients of their new treatment for gastroparesis, a condition marked by the failure of the stomach to properly empty its contents into the small intestine. In an article published online today in the journal Endoscopy, they describe how the placement of a small metal stent in the stomach can improve life for people who suffer from severe bouts of nausea, abdominal pain and vomiting that accompany the condition.

John Clarke, M.D., assistant professor of medicine at the Johns Hopkins University School of Medicine, and the article's lead author, used an endoscope to place a pyloric stent in three patients with delayed gastric emptying. The pylorus is the part of the stomach that connects to the small bowel.

"I think this new technique could play a big role in the treatment of gastroparesis," says Clarke, who also is clinical director of the Johns Hopkins Center for Neurogastroenterology. "Though it sounds a little bit unconventional, the safety of it may be better than anything else we have out there."

Clarke says recently developed flexible, silicone-covered metal stents have already been approved to treat some gastrointestinal obstructions, but until now have not been used to treat gastroparesis.

Typically, patients with gastroparesis don't get a lot of good news from their physicians. Stomach surgery or risky medications such as erythromycin and metoclopramide have been the go-to treatments for the condition, which can have serious health and quality-of-life consequences.

"There are few FDA-approved options for gastroparesis patients," Clarke says. "The only medicines that are approved have a number of adverse effects associated with them."

The National Institutes of Health estimates that 5 million Americans live with gastroparesis, a condition in which the contents of the stomach empty into the intestine slowly or not at all. Symptoms, including reflux, become chronic.

Using an endoscope, Clarke placed a self-expandable, coated metallic stent across the three patients' pyloric channels, holding the channels open and allowing the patients' stomachs to empty normally.

All three patients showed dramatic reductions in symptoms, Clarke says. One was a 15-year-old boy with chronic nausea and vomiting who had endured unsuccessful trials of erythromycin, metoclopramide, domperidone and promethazine. A second was a 54-year-old man with idiopathic gastroparesis who also didn't respond to medication, but had complete recovery after his stent placement. In a third patient, the stent migrated out of place and her pain came back, but after replacing it, the pain eased, Clarke reports. All were treated at The Johns Hopkins Hospital.

Clarke says the stent placement procedure isn't difficult.

"Technically it's pretty simple, and the risk appears to be minimal; if it doesn't work, you just take it out," he says. "Gastric surgery to stimulate emptying is riskier than endoscopy."

The number of patients diagnosed with gastroparesis is on the rise, Clarke says. "I'd estimate that 30 percent of my clinical practice comprises patients with gastroparesis."

Clarke says a larger clinical trial, which he expects to begin in the near future, is needed to provide longer follow-up of results and to identify which patients are likely to benefit the most from stents. "Our hope is that stent placement may become either a primary treatment option or a bridge technology to determine who can best benefit from surgery to improve stomach emptying."
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Johns Hopkins Medicine (JHM), headquartered in Baltimore, Maryland, is a $6.7 billion integrated global health enterprise and one of the leading health care systems in the United States. JHM unites physicians and scientists of the Johns Hopkins University School of Medicine with the organizations, health professionals and facilities of The Johns Hopkins Hospital and Health System. JHM's mission is to improve the health of the community and the world by setting the standard of excellence in medical education, research and clinical care. Diverse and inclusive, JHM educates medical students, scientists, health care professionals and the public; conducts biomedical research; and provides patient-centered medicine to prevent, diagnose and treat human illness. JHM operates six academic and community hospitals, four suburban health care and surgery centers, more than 38 primary health care outpatient sites and other businesses that care for national and international patients and activities. The Johns Hopkins Hospital, opened in 1889, was ranked number one in the nation for 21 years by U.S. News & World Report. Johns Hopkins Medicine
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