S1343 EndoFLIP and Pyloric Dilation for Gastroparesis Symptoms Refractory to Pyloromyotomy/Pyloroplasty

Abstract

INTRODUCTION: Gastroparesis (Gp) patients may undergo pyloromyotomy/pyloroplasty for chronic refractory symptoms. However, some patients have persistent symptoms. It is unknown if balloon dilation is an effective treatment strategy in these patients. We aimed to: 1) Assess if pyloric Through the Scope (TTS) balloon dilation results in symptom improvement in Gp patients with suboptimal response to pyloromyotomy/pyloroplasty; 2) Determine Endoscopic Functional Luminal Imaging Probe (EndoFLIP) characteristics of these patients before dilation. METHODS: Patients with severe Gp refractory to pyloromyotomy/pyloroplasty seen from 2/2019 to 3/2020 underwent pyloric TTS dilation to 18, 19 and 20 mm after assessing the pyloric characteristics at 30-, 40-, and 50-ml EndoFLIP distension volumes. Patients completed Gastroparesis Cardinal Symptom Index (GCSI) pre-procedurally, and GCSI and Clinical Patient Grading Assessment Scale (CPGAS) on follow-ups. RESULTS: Thirteen (10 females) patients (mean age 45.2 ± 5.1 years) with Gp and prior pyloric surgeries (laparoscopic pyloroplasty = 6, endoscopic pyloromyotomy = 5, laparoscopic pyloromyotomy = 1) presented with severe Gp symptoms (mean GCSI total score 3.4 ± 0.3, Table 1). TTS dilation was performed after assessing pyloric characteristics on EndoFLIP. Overall, there was improvement of symptoms at 1-month follow-up (mean GCSI total score 3.0 ± 0.4, P = 0.04, Table 2; mean CPGAS score 1.6 ± 0.5, P < 0.01, Table 3), with 5 patients (38%) reporting symptom improvement (4 moderately better; 1 somewhat better), and 8 with little (n = 1) or no (n = 7) improvement. Patients with symptom improvement reported symptoms of nausea (3), vomiting (1), and loss of appetite (1) improving the most. The patients with symptom improvement had lower pre-dilation pyloric EndoFLIP distensibility at 30 ml (4.7 ± 0.8 vs 13.2 ± 2.9 mm2/mmHg, P = 0.04), 40 ml (7.2 ± 1.0 vs 13.9 ± 2.1 mm2/mmHg, P = 0.02) and 50 ml (4.9 ± 1.0 vs 10.2 ± 1.9 mm2/mmHg, P = 0.04) than patients with little/no improvement. CONCLUSION: In Gp patients with refractory symptoms after pyloromyotomy/pyloroplasty, pyloric TTS dilation improved symptoms in about a third of the patients. Patients with symptom improvement had lower pre-dilation pyloric EndoFLIP distensibility suggesting incomplete myotomy, pyloric muscle regeneration or pyloric stricture. Pyloric EndoFLIP followed by TTS dilation seems to be a promising treatment for some patients with Gp symptoms refractory to pyloromyotomy/pyloroplasty.Table 1Table 2Table 3