Gastric Peroral Endoscopic Myotomy Research Articles

Is two better than one? Alternative techniques for gastric peroral endoscopic myotomy.

Is two better than one? Alternative techniques for gastric peroral endoscopic myotomy.

Practical management approach to gastroparesis.

Gastroparesis is a syndrome characterised by delayed gastric emptying in the absence of mechanical obstruction. Symptoms can include early satiety, abdominal pain, bloating, vomiting and regurgitation which cause significant morbidity in addition to nutritional deficits. There is a higher prevalence in diabetics and females, but the incidence in the Australian population has not been well studied. Management of gastroparesis involves investigating and correcting nutritional deficits, optimising glycaemic control and improving gastrointestinal motility. Symptom control in gastroparesis can be challenging. Nutritional deficits should be addressed initially through dietary modification. Enteral feeding is a second-line option when oral intake is insufficient. Home parenteral nutrition is rarely used, and only accessible through specialised clinics in the outpatient setting. Prokinetic medication classes that have been used include dopamine receptor antagonists, motilin receptor agonists, 5-HT4 receptor agonists and ghrelin receptor agonists. Anti-emetic agents are often used for symptom control. Interventional treatments include gastric electrical stimulation, gastric per-oral endoscopic myotomy, feeding jejunostomy and gastrostomy/jejunstomy for gastric venting and enteral feeding. In this article we propose a framework to manage gastroparesis in Australia based on current evidence and available therapies.

Impact of gastric per-oral endoscopic myotomy on static and dynamic pyloric function in gastroparesis patients.

Functional Lumen Imaging Probe (EndoFLIP) tests typically measure static pyloric parameters, but the pylorus exhibits phasic variations on manometry. Dynamic changes in pyloric function have not been quantified using EndoFLIP, and the impact of Gastric Per-Oral Endoscopic Myotomy (G-POEM) on static and dynamic pyloric activity in gastroparesis is unknown. EndoFLIP balloon inflation to 30, 40, and 50mL was performed to measure mean, maximum, and minimum values and variability in pyloric diameter and distensibility before and after G-POEM in 20 patients with refractory gastroparesis. The impact of phasic contractions on these pyloric measures was compared. G-POEM increased mean (P<.0001) and maximum (P=.0002) pyloric diameters and mean (P=.02) and maximum (P=.02) pyloric distensibility on 50mL EndoFLIP inflation but not intraballoon pressures or minimum diameters or distensibility. Temporal variability of pyloric diameter (P=.02) and distensibility (P=.02) also increased after G-POEM. Phasic coupled contractions propagating from the antrum through the pylorus were observed in 37.5% of recordings; other phasic activity including isolated pyloric contractions were seen in 23.3%. Variability of pyloric diameter and distensibility tended to be higher during recordings with phasic activity. Some pyloric responses to G-POEM were influenced by age, gastroparesis etiology, gastric emptying, and prior botulinum toxin injection. Pyloric activity exhibits dynamic changes on EndoFLIP testing in gastroparesis. G-POEM increases maximal but not minimal diameter and distensibility with increased variations, suggesting this therapy enhances pyloric opening but may not impair pyloric closure. Phasic pyloric contractions contribute to variations in pyloric activity.

667 GASTRIC PERORAL ENDOSCOPIC MYOTOMY (G-POEM) FOR THE TREATMENT OF REFRACTORY GASTROPARESIS: FINAL RESULTS FROM THE FIRST INTERNATIONAL PROSPECTIVE TRIAL

We previously reported the preliminary short-term outcomes of our prospective trial on gastric per-oral endoscopic myotomy (G-POEM) with promising results. To prospectively 1) evaluate the efficacy and safety of G-POEM and 2) assess factors associated with clinical success of G-POEM. In this prospective multicenter (4 US, 1 South America) study, patients with refractory gastroparesis - defined as symptoms refractory to standard medical therapy - underwent G-POEM between 11/2015 and 11/2018, and were followed for one year. Clinical symptoms (measured by Gastroparesis Cardinal Symptom Index [GCSI]) and quality of life (measured by Short Form 36 [SF-36]) were evaluated before and at 1-, 3-, 6-, and 12-month followups. Clinical success was defined as one score decrease in average GCSI with >25% decrease in at least 2 sub-scales. Gastric emptying study (GES) was performed before and 3 months after the G-POEM. Pylorus characteristics were measured by endoscopic functional luminal imaging probe (EndoFLIP) device pre and post G-POEM. A total of 80 patients (F 71%, mean age: 49yr) were enrolled. The most common etiology was idiopathic (41.3%), followed by postsurgical (35%) and diabetes (23.8%). All procedures were technically successful (technical success 100%). A total of 67 (84%) patients were followed up to one year with clinical success rate of 59.7%. GCSI and its subscales improved significantly following G-POEM (p<0.05) (Figure 1). Furthermore, 5 out of 8 domains of SF-36 including physical functioning, physical role, energy, emotional well-being, social functioning, general health, and health change improved significantly after G-POEM (p<0.05). A total of 5 adverse events, all rated as mild, were reported and included 3 symptomatic capnoperitoneum (treated by needle decompression), 1 mucosotomy (treated with stent replacement), and 1 thermal mucosal injury (treated with clipping). Pre and 3-month post G-POEM GES were performed in 53 (66.3%) patients. GES improvement and normalization were achieved in 34/53 (64.2%) and 25/53 (47.2%) patients, respectively. Following G-POEM, pylorus distensibility index (DI), measured with EndoFLIP, increased from 4.99 ± 2.57 to 6.74 ± 4.34 mm2/mmHg, and from 4.97 ± 3.02 to 6.99 ± 3.92 mm2/mmHg using 40- and 50-ml volume bags, respectively (p<0.05). Lower pre G-POEM DI using 40 ml bag was significantly associated with pre G-POEM disease severity (p=0.039). Baseline disease severity and increase in pylorus DI following G-POEM were significantly associated with clinical success (Table 1). G-POEM is safe and improves clinical symptoms and pylorus characteristics of patients with refractory gastroparesis. Disease severity predicts the one-year clinical success; thus, the procedure may be considered for patients with more severe gastroparesis symptoms.Table 1association between disease characteristics and one-year clinical success of G-POEMView Large Image Figure ViewerDownload Hi-res image Download (PPT)

Gastric per-Oral Endoscopic Myotomy for Refractory Gastroparesis: A Meta-Analysis

BackgroundThe emerging gastric per-oral endoscopic myotomy (G-POEM) is becoming an alternative treatment method for gastroparesis. This study aimed to evaluate the feasibility and safety of G-POEM for gastroparesis. MethodsRelevant publications were identified through searching PubMed, EMBASE, Cochrane Library, and Web of Science before April 1, 2019. Studies presenting the clinical data of G-POEM for the treatment of gastroparesis were included. Data about effectiveness and safety were extracted, pooled, and analyzed. Forest plots were graphed based on random effects models. ResultsA total of 272 patients representing 8 studies were eligible for analysis. The pooled rates of GCSI at preprocedure, 1–3 months, 6 months, and 12 months, were 3.25 (95% CI, 2.75–3.75), 1.80 (95% CI, 1.10–2.49), 1.56 (95% CI, 0.45–2.68), and 1.10 (95% CI, 0.75–1.45), respectively. The pooled results of 4-h GES pre- and post-G-POEM were 41.89% (95% CI, 32.75–51.03%) and 16.48% (95% CI, 9.83–23.14%), respectively. Furthermore, the pooled clinical response rate was 84% (95% CI, 77–89%). The GES improvement rate and GES normal rate were also analyzed, and the results were 84% (95% CI, 77–90%) and 53% (95% CI, 39–66%), respectively. Finally, the pooled adverse events rate was 12% (95% CI, 6–19%). ConclusionsG-POEM was shown to be feasible and safe for the treatment of gastroparesis with various etiologies, which could be a potential first-line therapy for certain patients. Future studies are needed to investigate the appropriate patients for G-POEM to explore the “most beneficial” subgroup of patients.

Opiates, the Pylorus, and Gastroparesis

Ingestion of food results in gastric accommodation. This is followed by development of antral contractions, and, after food is triturated to a small particle size, pyloric relaxation and antropyloroduodenal coordination result in the emptying of food from the stomach. Failure of pyloric relaxation may impede gastric emptying. Therefore, there has been increased interest in treating gastroparesis with pyloric interventions such as injection of botulinum toxin or gastric peroral endoscopic myotomy (G-POEM) (Table 1).

Endoscopic management of gastrointestinal motility disorders – part 1: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

ESGE recommends the use of a graded pneumatic dilation protocol in achalasia, starting with a 30-mm dilation and followed by a 35-mm dilation at a planned interval of 2 - 4 weeks, with a subsequent 40-mm dilation when there is insufficient relief, over both a single balloon dilation procedure or the use of a larger balloon from the outset.Strong recommendation, high quality of evidence, level of agreement 100 %.ESGE recommends being cautious in treating spastic motility disorders other than achalasia with peroral endoscopic myotomy (POEM).Strong recommendation, very low quality of evidence, level of agreement 87.5 %.ESGE recommends against the routine use of botulinum toxin injections to treat patients with non-achalasia hypercontractile esophageal motility disorders (Jackhammer esophagus, distal esophageal spasm). However, if, in individual patients, endoscopic injection of botulinum toxin is chosen, ESGE recommends performing injections into four quadrants of the lower esophageal sphincter and in the lower third of the esophagus.Strong recommendation, low quality of evidence, level of agreement 78.6 %.ESGE recommends that endoscopic pylorus-directed therapy should be considered only in patients with symptoms suggestive of gastroparesis in combination with objective proof of delayed gastric emptying using a validated test, and only when medical therapy has failed.Strong recommendation, very low quality of evidence, level of agreement 100 %.ESGE recommends against the use of botulinum toxin injection in the treatment of unselected patients with gastroparesis. Strong recommendation, high quality of evidence, level of agreement 92.9 %.ESGE recommends consideration of gastric peroral endoscopic myotomy (G-POEM) in carefully selected patients only, because it is an emerging procedure with limited data on effectiveness, safety, and durability. G-POEM should be performed in expert centers only, preferably in the context of a clinical trial.Strong recommendation, low quality of evidence, level of agreement 100 %.

Feasibility of using an led-probe in third-space endoscopy: a clinical study

BackgroundThird-space endoscopy is a novel, safe, and effective method for treating different gastrointestinal conditions. However, several failed endoscopic procedures are attributed to incomplete myotomy. Lighting devices are used to prevent organic injuries. We aimed to investigate the feasibility of using a hand-made LED-probe (LP) in third-space procedures.MethodsThis prospective study was conducted in a tertiary-care center in Mexico between December 2016 and January 2019. We included peroral endoscopic myotomy (POEM) and gastric peroral endoscopic myotomy(G-POEM) procedures. Pseudoachalasia, peptic ulcer, normal gastric emptying scintigraphy (GES) and prepyloric tumors were excluded. LP was used to guide or confirm procedures. Clinical and procedural characteristics were recorded and analyzed.ResultsSeventy third-space procedures were included (42POEM,28G-POEM), with an average patient age of 46.7 ± 14.3 and 43.7 ± 10.1 years, respectively. For the POEM and G-POEM groups, respectively, 18/42(42.9%) and 13/28(46.7%) patients were males; median procedure times were 50 (interquartile range [IQR]: 38–71) and 60(IQR: 48–77) min, median LP placement times were 5(IQR: 4-6) and 6(IQR: 5-7) min, mild adverse events occurred in 4(9.4%) and 4(14.2%) of cases, and clinical success at 6 months occurred in 100 and 85.7% of cases. Integrated relaxation pressure (IRP) improved from 27.3 ± 10.8 to 9.5 ± 4.1 mmHg (p < 0.001); retention percentage at 4 h also improved. LP was successfully placed and adequate myotomy confirmed including 14.2 and 17.8% of POEM and G-POEM difficult patients.ConclusionsUsing an LP is promising and allows guiding during third-space procedures either for submucosal tunnel creation or myotomy confirmation, with excellent safety and efficacy in clinical practice.

Pathophysiology, Aetiology and Treatment of Gastroparesis.

Gastroparesis is characterized by delayed gastric emptying, with symptoms such as nausea, vomiting and abdominal pain, in the absence of mechanical obstruction. In most cases, it is idiopathic although diabetes mellitus is another leading cause. The physiology of gastric emptying is a complex process which is influenced by various inputs including the central nervous system, enteric nervous system and gut hormones. Developments in our understanding of gastroparesis have now demonstrated dysfunction in these systems, thus disrupting normal gastric emptying. Once mechanical obstruction is excluded, gastric scintigraphy remains the gold standard for diagnosis although wireless motility capsule and breath testing are alternative methods for diagnosis. Treatment for gastroparesis is challenging, and widely available therapies are often limited either by their poor evidence for efficacy or concerns over their long-term safety profile. Novel prokinetic agents have shown initial promise in clinical trials, and new endoscopic techniques such as gastric per-oral endoscopic myotomy are emerging. These new treatment modalities may provide an option in refractory gastroparesis with the adage of reduced morbidity compared to surgical treatments.

Comprehensive Analysis of Adverse Events Associated with Gastric Peroral Endoscopic Myotomy: An International Multicenter Study.

Gastric peroral endoscopic myotomy (G-POEM) has emerged as an effective management approach for patients with refractory gastroparesis. This study aims to comprehensively study the safety of G-POEM and describe the predictive factors of adverse events (AEs) occurrence. This study is a retrospective study involving 13 tertiary care centers (7 USA, 1 South America, 4 Europe, and 1 Asia). Patients who underwent G-POEM for refractory gastroparesis were included. Cases were identified by the occurrence of AEs. For each case, two controls were randomly selected and matched for age (± 10years), gender, and etiology of gastroparesis. A total of 216 patients underwent G-POEM for gastroparesis. Overall, 31 (14%) AEs were encountered [mild 24 (77%), moderate 5 (16%), and severe 2 (6%)] during the duration of the study. The most common AE was abdominal pain (n = 16), followed by mucosotomy (n = 5) and capnoperitoneum (n = 4), and AEs were most commonly identified within the first 48-h post-procedure 18 (58%). The risk of adverse event occurrence was significantly higher for endoscopists with experience of < 20 G-POEM procedures (OR 3.03 [1.03-8.94], p < 0.05). G-POEM seems to be a safe intervention for refractory gastroparesis. AEs are most commonly mild and managed conservatively. Longitudinal mucosal incision, use of hook knife, use of clips for mucosal closure and endoscopist's experience with > 20 G-POEM procedures is significantly associated with decreased incidence of AEs.

Role of endoscopic functional luminal imaging probe in predicting the outcome of gastric peroral endoscopic pyloromyotomy (with video)

Endoluminal functional luminal imaging probe (EndoFLIP) is an imaging tool that measures the physiologic characteristics of GI sphincters. In this study, we used EndoFLIP to evaluate the association between the pyloric physiologic measurements and the clinical outcomes of gastric peroral endoscopic myotomy (G-POEM) in patients with refractory gastroparesis. Thirty-seven patients from 5 centers who underwent G-POEM for management of refractory gastroparesis and had EndoFLIP measurements were evaluated. Cross-sectional area (CSA), balloon pressure, and the distensibility index (DI) of the pylorus were evaluated by EndoFLIP at 40 mL and 50 mL balloon fills before and after G-POEM. One-year clinical success and change in gastric emptying study 3 months after the G-POEM procedure were compared with the EndoFLIP measurements. Clinical success was achieved in 26 (70%) patients. Post-G-POEM CSA and DI were significantly higher in the clinical success group with both 40-mL volume distension (CSA: 89.9 ± 64.8 vs 172.5 ± 71.9mm2, P=.003; DI: 5.8 ± 4.4 vs 8.8 ± 6.1mm2/mm Hg, P=.043) and 50-mL volume distention (CSA: 140.1 ± 89.9 vs 237.5 ± 80.3mm2, P=.003; DI: 5.6 ± 3.3 vs 9.9 ± 6.6mm2/mm Hg, P=.049). CSA using 40-mL volume distention with an area under the curve of 0.83 yielded a specificity of 91% and a sensitivity of 71% at a cutoff point of 154mm2. Post-G-POEM CSA of the pylorus is associated with clinical success and improvement in a gastric emptying scan after G-POEM. EndoFLIP measurements of the pylorus have the potential to be used as a tool to predict the clinical outcome of G-POEM.

Gastric per-oral endoscopic myotomy (G-POEM) is a promising treatment for refractory gastroparesis: a systematic review and meta-analysis.

to evaluate the efficacy and safety of gastric per-oral endoscopic myotomy (G-POEM) for the treatment of refractory gastroparesis. PubMed, Embase and Cochrane databases were searched and used for study inclusion. Clinical studies since January 2013 to October 2019 were identified as suitable for inclusion. Conference papers, review articles, case reports, animal studies, letters, studies with repetitive data, studies that did not mention the Gastroparesis Cardinal Symptom Index (GCSI) score/gastric emptying scintigraphy (GES) hours or were not indicated in the standard form were excluded. GCSI score, GCSI reduction, gastric emptying scintigraphy at four hours (GES-4h) and GES time (GET) reduction were considered as major indexes and the meta-analysis was achieved using Review Manager 5.3. Research bias was measured according to Cochrane handbook. nine studies were included with a total of 235 patients that underwent G-POEM, and the technical success rate was 100%. After G-POEM, patients reported changes in GCSI score (6/9 studies, mean difference 1.41 [CI: 0.93, 1.88], p < 0.0001), GCSI reduction (8/9 studies, odds ratio 3.00 [CI: 2.24, 4.03], p < 0.0001), GES-4h (8/9 studies, mean difference 23.78 [CI: 19.88, 27.68], p < 0.00001) and GET reduction (6/9 studies, odds ratio 3.50 [CI: 2.12, 5.78], p < 0.00001). The intra-procedure complication rate was 5.1% (12/235), including capnoperitoneum (seven cases) and accidental mucotomy (five cases). The post-procedure complication rate was 6.8% (16/235), including abdominal pain (three cases), bleeding (three cases), ulcer (one case), difficulty swallowing (one case) and others (eight cases). Both per- and post-procedure complications were easily managed by conservative or endoscopic treatments. the results show that gastroparesis patients can benefit from G-POEM, the success rate was impressive and the complication rate was relatively low. However, caution is necessary when interpreting the results, primarily due to the limitations of uncontrolled studies. Randomized control studies are still needed for further evaluations.

The first experience with gastric peroral endoscopic myotomy (G-POEM) for gastroparesis

The first experience with gastric peroral endoscopic myotomy (G-POEM) for gastroparesis

Safety and Feasibility of Per-Oral Pyloromyotomy as Augmentative Therapy after Prior Gastric Electrical Stimulation for Gastroparesis

For medically refractory diabetic or idiopathic gastroparesis, gastric electrical stimulation (GES) is an excellent option for symptom control; however, a small subset of patients may develop recurrent or persistent symptoms. Per-oral pyloromyotomy (POP, also described by some authors as gastric per-oral endoscopic myotomy or G-POEM) is an emerging therapy for medically refractory gastroparesis. This study investigated the safety and feasibility of POP after previous GES for recurrent or persistent gastroparesis. We retrospectively identified all patients undergoing POP between January 2016 and December 2017, with GES in situ. Patient characteristics, gastroparesis etiology, and procedural data were collected. Symptoms were assessed with the Gastroparesis Cardinal Symptom Index (GCSI) both before and 30 to 90 days after POP. Standard pre- and post-procedure 4-hour gastric emptying tests were obtained when available. There were 22 patients who met inclusion criteria (81.8% female, mean age 42.3 ± 12.4 years). Causes of gastroparesis were diabetes in 38.1%, and idiopathic in 61.9%. The average time since GES insertion was 3.45 years. Mean preoperative 4-hour gastric retention was 50.1%. Most POP procedures were performed in the operating room (90.9%), with mean operative time of 40 minutes and a 1.4-day length of stay. There were 4 readmissions within 30 days, but no POP-related complications. Overall, GCSI improved by an absolute reduction of 1.63 points (p= 0.002), with significant improvements in all sub-scores. Of 11 patients with post-procedural motility or emptying studies available, 7 were normal. Per-oral pyloromyotomy appears to be safe and feasible for patients with recurrent gastroparesis symptoms after GES. Both symptoms and motility significantly improved in the short-term. These data replicate similar data suggesting laparoscopic pyloroplasty as an effective augmentative therapy after GES, but may provide a less invasive option for patients.

Clinical efficacy of gastric per-oral endoscopic myotomy (G-POEM) in the treatment of refractory gastroparesis and predictors of outcomes: a systematic review and meta-analysis using surgical pyloroplasty as a comparator group.

Gastric peroral endoscopic myotomy (G-POEM) is a novel minimally invasive technique in endosurgery. Data is limited as to its efficacy, safety, and predictive factors. We conducted this meta-analysis to evaluate the clinical outcomes of G-POEM and used the outcomes of surgical pyloroplasty as a comparator group in the treatment of refractory gastroparesis. We searched multiple databases from inception through March 2019 to identify studies that reported on G-POEM and pyloroplasty in gastroparesis. Our primary outcome was to analyze and compare the pooled rates of clinical success, in terms of Gastroparesis Cardinal Symptom Index (GCSI) score and 4-h gastric emptying study (GES) results, with G-POEM and pyloroplasty. Three hundred and thirty-two and 375 patients underwent G-POEM (11 studies) and surgical pyloroplasty (seven studies), respectively. The pooled rate of clinical success, based on the GCSI score, with G-POEM was 75.8% (95% CI 68.1-82.1, I2 = 50) and with surgical pyloroplasty was 77.3% (95% CI 66.4-85.4, I2 = 0), with no significance, p = 0.81. The pooled rate of clinical success, based on the 4-hour GES results, with G-POEM was 85.1% (95% CI 68.9-93.7, I2 = 74) and with surgical pyloroplasty was 84% (95% CI 64.4-93.8, I2 = 81), with no significance, p = 0.91. The overall adverse events were comparable. Based on meta-regression analysis, idiopathic gastroparesis, prior treatment with botulinum toxin and gastric stimulator seemed to predict clinical success with G-POEM. G-POEM demonstrates clinical success in treating refractory gastroparesis. Idiopathic gastroparesis, prior treatment with botulinum injections and gastric stimulator appear to have positive predictive effects on the 4-h GES results after G-POEM. Outcomes seem comparable to surgical pyloroplasty.

903 Clinical Efficacy of Gastric Per-Oral Endoscopic Myotomy in the Treatment of Refractory Gastroparesis and Predictors of Successful Outcomes: A Systematic Review and Meta-Analysis

INTRODUCTION: Options to treat medically refractory gastroparesis are limited. Gastric peroral endoscopic myotomy (G-POEM) is a novel minimally invasive technique in endosurgery that has shown promising results. Data is limited as to its efficacy, safety, predictive factors and its comparability to surgical pyloroplasty. The aim of our study was to synthesize and analyze the clinical outcomes of GPOEM by meta-analysis methods. METHODS: We searched multiple databases from inception through March 2019 to identify studies that reported on G-POEM and surgical pyloroplasty in gastroparesis. Our primary outcome was to analyze the pooled rates of gastroparesis cardinal symptom index (GCSI) score and 4-hr gastric emptying study (GES) results, with G-POEM. Similar outcomes with surgical pyloroplasty was used as a comparator group. RESULTS: 332 and 375 patients underwent G-POEM (11studies) and pyloroplasty (7studies), respectively. The pooled rate of clinical success, based on the GCSI score, with G-POEM was 75.8% (95% CI 68.1-82.1, I2 = 50) and with pyloroplasty was 77.3% (95% CI 66.4-85.4, I2 = 0), with no significance,P = 0.81. The pooled rate of clinical success, based on the 4-hour GES results, with GPOEM was 85.1% (95% CI 68.9-93.7, I2 = 74) and with pyloroplasty was 84% (95% CI 64.4-93.8, I2 = 81), with no significance, P = 0.91. The pooled rate of mean pre-G-POEM GCSI score was 3.4 (95% CI 3.1-3.7, I2 = 89) and post-G-POEM GCSI score was 1.8 (95% CI 1.4-2.1, I2 = 89), with statistical significance (P = 0.001). The pooled pre-G-POEM 4-hr GES was 49.9% (95% CI 41.6-58.3, I2 = 94) and post-G-POEM 4-hr GES was 20.6% (95% CI 12.3-28.8, I2 = 77), with statistical significance (P = 0.001). The pre and post pyloroplasty 4-hr GES results were 36% (95% CI 32.7-39.3, I2 = 88) and 3.9% (95% CI 2.3-5.5, I2 = 43), respectively (P = 0.001). The pre and post pyloroplasty GCSI score was not analyzed due to paucity in data. The overall adverse events were comparable (11%, 5.9-19.8, I2 = 66 vs 11.4%, 5-24, I2 = 69, P = 0.95). Based on meta-regression analysis, idiopathic-gastroparesis, prior treatment with botulinum toxin and gastric-stimulator seemed to predict clinical success with G-POEM. CONCLUSION: G-POEM demonstrates clinical success in treating refractory gastroparesis with comparable outcomes to pyloroplasty. Idiopathic gastroparesis, prior treatment with botulinum injection and gastric stimulator appear to have positive predictive effects on the 4-hr GES results after G-POEM.

Endoscopic techniques for myotomy of the lower esophageal sphincter and pylorus.

Peroral endoscopic myotomy (POEM) and gastric peroral endoscopic myotomy (G-POEM) are minimally invasive endoscopic procedures for the treatment of esophageal motility disorders and refractory gastroparesis, respectively. In this review, we highlight the most recent publications on the technical aspects of POEM and G-POEM. POEM has evolved into a standard therapeutic option in patients with all achalasia subtypes with excellent durability and safety profile. G-POEM is a novel endoscopic procedure with promising results in terms of efficacy, safety, and symptom improvement in patients with refractory gastroparesis. POEM and G-POEM are novel endoscopic procedures. Practice patterns vary among endoscopists and procedure techniques continue to evolve. Comparative studies examining outcomes of different techniques are needed.

Lesser curve approach to gastric peroral endoscopic myotomy: a case series

Background and AimsGastric peroral endoscopic myotomy (GPOEM) is a promising treatment for refractory gastroparesis. Initially, endoscopists performed GPOEM along the greater curve of the stomach. We, herein, present a novel modification with a lesser curve approach that offers the advantages of shorter tunnel and possibly better myotomy.MethodsThree patients with refractory gastroparesis underwent GPOEM by use of the lesser curve approach. Two of the patients had a prior GPOEM by the traditional greater curve approach. All procedures were performed with the patient under general anesthesia. The specific tools used for incision, dissection, and myotomy are described. The patients were followed up closely, and the gastroparesis cardinal symptom index (GCSI) was calculated before, and 4 weeks after, the procedure.ResultsThe pyloric ring was exposed very well with the lesser curve approach. The mean procedure time was 48 ± 12 minutes. No immediate or late adverse events were observed. All patients had significant improvement in the GCSI 4 weeks after GPOEM, with resolution of gastroparesis symptoms. The mean follow-up time was 6 months.ConclusionThe lesser curve approach to GPOEM provides an excellent exposure to the pyloric ring and can be used as a primary or a salvage technique for the treatment of refractory gastroparesis.

Peroral endoscopic myotomy (POEM) for achalasia.

Achalasia is an uncommon disorder that results from the degeneration of ganglion cells of the myenteric plexus in the lower esophageal wall. It is manifested by a loss of peristalsis in the lower part of the esophagus and failure of the lower esophageal sphincter (LES) to relax. Peroral endoscopic myotomy (POEM) is a minimally invasive intervention that aims to treat achalasia. It is regarded as the endoscopic equivalent of Heller myotomy. POEM is a form of natural orifice transluminal endoscopic surgery that is completed by creating a submucosal tunnel in the lower part of esophagus to reach the inner circular muscle bundles of the LES to perform myotomy, while preserving the outer longitudinal muscle bundles. The result is decreased resting pressure of the LES, facilitating the passage of ingested material. POEM was initially introduced to treat achalasia by targeting the LES. POEM has expanded to include gastric POEM (G-POEM), myotomy of the pyloric sphincter to treat gastroparesis, and per rectal endoscopic myotomy to treat adult Hirschsprung's disease.

Gastric peroral endoscopic myotomy for gastroparesis: A systematic review of efficacy and safety

Gastric peroral endoscopic myotomy for gastroparesis: A systematic review of efficacy and safety