Background and Aims
The pathophysiology of some GI neuromuscular diseases remains largely unknown. This
is in part due to the inability to obtain ample deep gastric wall biopsies that include
the intermuscular layer of the muscularis propria (MP) to evaluate the enteric nervous
system, interstitial cells of Cajal (ICCs), and related cells. We report on a novel
technique for gastric endoscopic muscle biopsy (gEMB).
Methods
Patients with idiopathic gastroparesis were prospectively enrolled in a feasibility
study by using a novel “no hole” gEMB. Main outcome measures were technical success,
adverse events, and histologic confirmation of the intermuscular layer, including
myenteric neurons and ICC. The gEMB was a double resection clip-assist technique.
A site was identified on the anterior wall of the gastric body as recommended by the
International Working Group on histologic techniques. EMR was performed to unroof
and expose the underlying MP. The exposed MP was then retracted into the cap of an
over-the-scope clip. The clip was deployed, and the pseudopolyp of MP created was
resected. This resulted in a no-hole gEMB.
Results
Three patients with idiopathic gastroparesis underwent gEMB. Patients had severe delayed
gastric emptying with a mean (± standard deviation [SD]) of 49 ± 16.8% of retained
gastric contents at 4 hours. They had no history of gastric or small-bowel surgery
and did not use steroids or other immunosuppressive drugs. The gEMB procedure was
successfully performed, with no procedural adverse events. Postprocedural abdominal
pain was controlled with nonsteroidal anti-inflammatory agents and opioid analgesics.
Mean length of resected MP was 10.3 ± 1.5 mm. Mean procedure time was 25.7 ± 6 minutes.
Hematoxylin and eosin (H&E) staining of tissue samples confirmed the presence of both
inner circular and outer longitudinal muscle, as well as the intermuscular layer.
H&E staining showed reduced myenteric ganglia in 1 patient. In 2 patients, specialized
immunohistochemistry was performed, which showed a marked decrease in myenteric neurons
as delineated by an antibody to protein gene product 9.5 and a severe decrease in
ICC levels across the muscle layers. At 1 month follow-up, upper endoscopy showed
a well-healed scar in 2 patients and minimal ulceration with a retained clip in 1
patient. CT of the abdomen confirmed the integrity of the gastric wall in all patients.
Because of lack of an immune infiltrate in the resected samples, patients were not
considered suitable for immunosuppressive or steroid therapy.
Conclusions
gEMB is feasible and easy to perform, with acquisition of tissue close to surgical
samples to identify myenteric ganglia, ICCs, and multiple cell types. The ability
to perform gEMB represents a paradigm shift in endoscopic tissue diagnosis of gastric
neuromuscular pathologies.
Abbreviations:
gEMB (gastric endoscopic muscle biopsy), ICC (interstitial cells of Cajal), MP (muscularis propria)To read this article in full you will need to make a payment
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Article info
Publication history
Published online: April 26, 2016
Accepted:
April 17,
2016
Received:
February 22,
2016
Footnotes
DISCLOSURE: The study was supported by the Weissman Fund (CJ Gostout), National Institutes of Health grants DK68055 and DK57061 (Farrugia) and the Center for Individualized Medicine (E Rajan), Mayo Clinic, Rochester, Minnesota. All other authors disclosed no financial relationships relevant to this publication.
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Copyright
Copyright © 2016 by the American Society for Gastrointestinal Endoscopy
