Sa1927 G-POEM IS AN EFFECTIVE THERAPEUTIC INTERVENTION FOR POST-SURGICAL GASTROPARESIS

Abstract

Postsurgical gastroparesis (PSG) is a common cause of major morbidity following foregut surgery and is a consequence of vagal nerve injury resulting in both gastric atony and pylorospasm. PSG is difficult to treat and often refractory to medical or surgical interventions, however, gastric per-oral endoscopic myotomy (G-POEM) has recently been reported as a minimally invasive therapeutic alternative. To evaluate the efficacy and safety of G-POEM, as well as, identify predictors of clinical response to therapy. Patients with refractory PSG were included and underwent trans-pyloric stenting (Niti-S, Taewoong Medical) following initial pre-procedure evaluation. Stents were anchored in two locations at the proximal end of the stent and remained in place for 1 month. Symptom improvement was assessed on a 10 point scale following stent placement and patients were only offered G-POEM if they experienced clinical improvement (score > 5) and return of symptoms following stent removal. Pyloric diameter and pressure measurements were obtained at the time of the initial endoscopy and 1-2 months post procedure using the functional luminal imaging probe (FLIP). A total of 8 patients with PSG with a median (IQR) time from surgery of 52.5 (25 - 86.2) months were enrolled (Table). All patients reported clinical improvement following stent placement with a mean (SD) score of 7.1 (2.0) and symptom recurrence upon stent removal. Stent migration occurred in 5/8 (63%) patients despite anchoring with suture. The mean (SD) time to migration was 11.4 (9.1) days. Migrated stents were either retrieved endoscopically or passed spontaneously without further complications. G-POEM was technically successful in all patients with no associated adverse events (Table). Seven of 8 (87.5%) patients reported symptomatic improvement following treatment with a mean (SD) improvement score of 7.4 (2.8). One patient did not improve following G-POEM despite a positive response to trans-pyloric stenting. A second G-POEM was performed for this patient, however the patient failed to achieve symptomatic improvement. The mean (SD) increase in distensibility index (cross-sectional area/pressure) at a 60cc fill volume, measured using FLIP, for those patients with improvement in their symptoms was 1.4 (3.1) mm2/mmHg. G-POEM is a safe and effective intervention for PSG patients. Trans-pyloric stent placement may be an accurate predictor of future response to G-POEM, however stent migration was frequently observed despite suture fixation. Further investigation is needed to determine the utility of FLIP for PSG patients undergoing G-POEM.Tabled 1Patient and Procedure CharacteristicsN = 8Age, mean (SD)57.5 (12.6)Female, N (%)3 (37.5%)SurgeryNissen, N (%)2 (25%)Esophagectomy, N (%)6 (75%)Improvement with trans-pyloric stent, mean (SD)7.1 (2.0)Stent migration, N (%)5 (62.5%)Time to migration (days), mean (SD)11.4 (9.1)Procedure time (minutes), mean (SD)41.6 (9.1)Submucosal tunnel length (cm), mean (SD)4.8 (1.3)Myotomy length (cm), mean (SD)2 (0.0)Hospital stay (days), mean (SD)1.25 (0.5)Improvement with G-POEM, mean (SD)7.4 (2.8) Open table in a new tab