S1866 Gastric Per Oral Endoscopic Myotomy (G-POEM) for Management of Refractory Gastroparesis

Abstract

INTRODUCTION: Gastroparesis is a functional disorder defined by delayed gastric emptying in the absence of mechanical obstruction. The main etiologies are diabetes, chronic narcotic use, postsurgical complications and idiopathy. Gastroparesis manifests varied symptoms such as early satiety, nausea, vomiting, bloating and pain. Treatment includes dietary changes, glycemic control and prokinetic medications although clinical response can be limited. Patients with refractory gastroparesis have the possibility to undergo invasive endoscopic or surgical intervention. These include pyloric dilation, botulinum neurotoxin (Botox) injections and laparoscopic pyloromyotomy. Gastric per oral endoscopic myotomy (G-POEM) has emerged as a new and effective technique for treating gastroparesis using similar principles and techniques as POEMs for esophageal disorders. CASE DESCRIPTION/METHODS: A 20-year-old female patient with a history of autonomic dysfunction and refractory gastroparesis was treated utilizing the G-POEM. An injection of 10 ml of methylene blue and saline was placed in the antrum of the stomach 3 cm proximal to the pylorus. A 1-2 cm longitudinal mucosotomy was made using a Type-I Hybrid Knife. The submucosal tunnel was created by dissecting through the submucosal fibrous and scar tissue. The dissection proceeded along the muscularis layer of the gastric wall and bleeding vessels were stopped through coagulation. Tunneling continued past the pylorus until the duodenal mucosa bulb was visualized. Once the tunnel was completed, the pyloromyotomy was performed using the hybrid knife until the pyloric muscle was fully divided. The submucosal tunnel was closed using endoscopic suturing. No severe complications occurred. The patient was stable having clear liquids and in no pain. A liquid diet for 3 days and semi-solid diet for 7 days were recommended. DISCUSSION: The exact pathogenesis of gastroparesis is unknown. Pharmacotherapy has limited efficacy with undesirable side effects. Prokinetics and selective motilin agonists are the mainstay of treatment and therapeutic options have focused on relieving pylorospam through gastric electrical stimulation (GES) with some success. G-POEM is an evolving procedure and is becoming a viable alternative to surgery. Several studies presented a high technical and clinical success rate with a short endoscopic operative time with averages ranging from 30 to 70 minutes. Hospital stay duration and occurrence of adverse events remain low.Figure 1.: Initial 1–2 cm longitudinal mucosotomy to create the submucosal tunnel.Figure 2.: Endoscopic myotomy of the pylorus.Figure 3.: Endoscopic suturing to close the initial mucosotomy site.