Laparoscopic Pyloroplasty Research Articles

Laparoscopic Versus Conventional Y-U Pyloroplasty in Dogs: A Comparative Study of Pain, Stress, and Duration

BACKGROUND: Background: Y-U pyloroplasty is a surgical approach that is used to relieve pyloric stenosis. The study of different aspects of laparoscopic Y-U pyloroplasty instead of conventional approaches seems to be an appropriate alternative for the development of such surgeries in animals, as pyloric stenosis is an uncommon but important disease. OBJECTIVES: The present study aimed to describe the laparoscopic Y-U pyloroplasty in small animals as a new surgical technique, and to compare the duration of surgery, level of surgical stress, and postoperative pain of this method with the conventional Y-U pyloroplasty. It is important to note that this is the first time that laparoscopic Y-U pyloroplasty was performed in dogs. METHODS: A total of eight intact male and female mixed breed dogs were randomly divided into two groups of conventional (n=4) and laparoscopic (n=4) pyloroplasty. Operation time, blood glucose concentration, plasma cor-tisol levels, gastric emptying time, pyloric lumen, and diameter and width of pyloric ring, as well as the University of Melbourne Pain Scale (UMPS) were measured in both groups during pre and postoperative intervals. RESULTS: As a result, the mean operation time for conventional group was significantly lower than that for lapa-roscopic group (38.75±3.15 min vs. 116.25±14.34 min, p <0.05). Blood glucose concentrations in both groups elevated rapidly until 3 hours after surgery and then decreased until 24 hours. Plasma cortisol level in laparoscopic group, however, elevated rapidly until 5 hours after surgery. On the other hand, pyloric diameter and width of pyloric ring significantly increased in both groups. The UMPS in dogs undergoing conventional Y-U pyloroplasty was significantly higher than that in those undergoing laparoscopic Y-U pyloroplasty (p <0.001). Furthermore, pain and gastric emptying time decreased in all dogs. CONCLUSIONS: This study suggests that laparoscopic Y-U pyloroplasty is an applicable minimal invasive sur-gery that is performed through small incisions for the treatment of pyloric stenosis in dogs.

Innovations in Gastroparesis Treatment (from Pyloroplasty to Per Oral Pyloromyotomy)

AbstractGastroparesis is a debilitating disorder of the gastrointestinal tract which significantly decreases quality of life. Health care costs and utilization have increased for gastroparesis over the last two decades. Historically gastric pacemaker placement and various open and laparoscopic emptying procedures have been practiced for the treatment of gastroparesis. More recently, the per oral pyloromyotomy procedure has been developed after a rich history of innovation in endoscopic surgery, following the report of laparoscopic pyloroplasty as a primary treatment for gastroparesis. Per oral pyloromyotomy is a successful management option for appropriately selected patients who suffer from medically refractory gastroparesis. This article describes the nature of the problem of gastroparesis, the timeline of the development of the per oral pyloromyotomy procedure, a review of the literature, and the indications for and details of the procedure itself.

Per Oral Pyloromyotomy for Treatment of Gastroparesis in a Pediatric Patient

Per Oral Pyloromyotomy for Treatment of Gastroparesis in a Pediatric Patient

Duration, Stress, and Pain Evaluation of Laparoscopic versus Conventional Heineke-Mikulicz Pyloroplasty

Pyloric stenosis is an uncommon but important gastric outflow disease. Heineke-Mikulicz (H-M) pyloroplasty is one of the pyloroplasty techniques used for the treatment of such diseases. A laparoscopic pyloroplasty is an effective and preferred alternative technique to conventional surgeries. This study aims to compare the duration of surgery, surgical stress level measurement, and postoperative pain in laparoscopic H-M pyloroplasty in normal dogs with a conventional pyloroplasty technique. Eight intact adult mixed breed dogs (5 females and 3 males) were used in this study. Animals were randomly divided into two groups of conventional open (n = 4) and laparoscopic (n = 4) H-M pyloroplasty. Blood glucose concentration, plasma cortisol level, as well as pyloric features including a pyloric lumen, pyloric diameter, pyloric width with ultrasonography, and gastric emptying time with contrast radiography and the University of Melbourne Pain Scale (UMPS) value, were measured in both groups. The mean operation time in the laparoscopic group was longer than that of the conventional group (55.00 ± 15.00 vs. 35.00 ± 4.56 min); however, this difference was not statistically significant. Blood glucose concentration in the laparoscopic group elevated rapidly until 3 hours after the operation and then decreased in 24 hours while blood glucose concentration in the conventional group slowly increased until 24 hours. The UMPS value at 3 hours after conventional H-M pyloroplasty was higher than that of laparoscopic H-M pyloroplasty (19.25 ± 0.75 vs. 6.50 ± 0.96, p < 0.001). Gastric emptying time significantly decreased in both groups. According to the results, in addition to reducing pain and stress, laparoscopic H-M pyloroplasty decreased gastric emptying time in all patients with no morbidity and appears to be a less invasive alternative technique for the management of gastric outflow disease.

Impact of Robotic Versus Laparoscopic Pyloroplasty on Short- and Long-term Outcomes in Patients with Gastroparesis

Impact of Robotic Versus Laparoscopic Pyloroplasty on Short- and Long-term Outcomes in Patients with Gastroparesis

Gastric peroral myotomy (G-POEM) in patients with delayed emptying function of the stomach

Introduction. Disorders in the gastric evacuation function are met in patients with gastroesophageal reflux. In most cases, simultaneous laparoscopic pyloroplasty can solve the problem. As an alternative to surgical pyloroplasty to treat gastroparesis, a new technique has been proposed – peroral submucosal pyloromyotomy or gastric peroral endoscopic myotomy (G-POEM). Recently, this endoscopic surgery has been implemented in adults and in newborns with congenital hypertrophic pyloric stenosis to treat gastric paresis. In the present work, the authors describe this technique and short-term results after G-POEM in a child who had previously been operated on for gastroesophageal reflux.Material and methods. Peroral submucosal pyloromyotomy was performed in a girl of 5 y.o. with impaired motor-evacuation function of the stomach after surgical treatment of gastroesophageal reflux disease at the age of two . For 3 years, the child had therapy which included antiemetics and H2-receptor blockers. However, clinical symptoms constantly recurred, and it was decided to make a thorough examination of the patient. At the contrast examination of upper gastrointestinal tract, stomach enlargement and slow transit of the contrast preparation into the duodenum were seen. Fibrogastroduodenoscopy confirmed the normal function of the fundoplication cuff and found a cause of impaired gastric emptying. A contracted gastric outlet as a spasmodic pylorus was found to be an obstacle for normal stomach evacuation function. A narrow hole in the pylorus was found. A 5.4 mm gastroscope could pass through it. The patient had a complete peroral endoscopic submucosal pyloromyotomy. The technique of this surgery consisted in creating a submucosal tunnel at 4 cm before the pylorus and in dissecting the hypertrophied muscle layer by Ramstedt incision using an electrocoagulation knife. After the end of surgery, the incision on the mucous layer was closed with special clamps.Results. Surgical time lasted for 45 minutes. There were no intraoperative complications: bleedings and mucosal perforation . The patient began to eat in 6 hours after the surgery. The transition to full enteral feeding lasted for 24 hours. The child was discharged from the hospital next day in good condition. At the follow-up examination 6 months after surgery, the girl had weight and height typical for her age. There were no signs of dysphagia, abdominal distension, nausea and vomiting any more . There were no post-operative scarring on the child’s abdominal wall.Conclusion. Peroral submucosal pyloromyotomy is technically implementable, safe and effective for treating disorders of stomach evacuation function in children. Further research is needed to find the place of this technique in the treatment of gastric outlet obstruction.

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

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

Per oral pyloromyotomy utilizing a lesser curvature approach: how we do it.

The treatment of gastroparesis refractory to medical therapy has evolved to include purely endoscopic techniques. Per oral pyloromyotomy (POP) has evolved from traditional laparoscopic or open pyloroplasty to become a safe and effective minimally invasive option for patients with gastroparesis. As compared to laparoscopic pyloroplasty (LP), POP produces similar improvements in gastric emptying and symptom mitigation, while having shorter lengths of stay. There are slight variations in technique that vary by institution. Described here is a technique utilizing a lesser curve approach, with a mucosotomy closure using clips in an effort to maximize efficiency of the procedure. Preoperative workup includes a scintigraphic gastric emptying study or a wireless motility capsule study, and the Gastroparesis Cardinal Symptom Index (GCSI). After an upper endoscopy, the procedure begins with injection into the submucosal space with methylene blue in saline on the lesser curve, 3-5cm proximal to the pylorus. A 1.5cm incision is then made with the ERBE hybrid knife. A submucosal tunnel is created past the distal end of the pylorus, and the muscle is hooked, and divided with the hybrid knife. The mucosotomy is closed with clips (Boston Scientific Resolution 360, Boston, MA) after the completion of the myotomy. Post-operatively, patients are discharged home after an overnight stay with a proton pump inhibitor, sucralfate, and a full liquid diet for 2 weeks. A lesser curve approach with mucosotomy closure using clips is a safe, effective, and efficient modality for performing POP. As more centers adopt POP as a tool for gastroparesis management, the lesser curve method limits the length of the submucosal tunnel needed, and allows for wide adoption of the technique.

Comparative study of outcome and complications of surgical management of benign gastric outlet obstruction

Background: Gastric outlet obstruction (GOO) implies complete or incomplete obstruction of the distal stomach, pylorus, or proximal duodenum. There are many causes of benign GOO like acid ingestion, pyloric stenosis, peptic ulcer etc. The main aims of this study were to compare the perioperative morbidity and short and long term complications of different procedures for benign gastric outlet obstruction.Methods: This non-randomised retrospective study was undertaken in the department of General Surgery, SMIMER Hospital, Surat, Gujarat, India from August 2016 to July 2019. Thirty patients had been operated during this period and included in the study. Records of all 30 patients were retrieved and analysed. All these patients underwent pre-operatively upper GI scopy with biopsy and CECT abdomen.Results: Nausea and Vomiting was most common symptoms at time of presentation in our study. Incidence of wound infection in open Gastrojejunostomy group was very high i.e. 25% and hospital stay was also very high in open Gastrojejunostomy group. Post-operative PPI dependence was more common in Gastro-jejunostomy group in all follow up and there was no any requirement of PPI in Heineke-Mikukicz and Finney’s pyloroplasty group.Conclusions: On comparison of different surgical modalities for management of benign GOO, all surgeries performed laparoscopically were safe and carried comparatively less morbidities (perioperative, short term and long term) in comparison to open methods. Among all three laparoscopic procedures, outcome of laparoscopic pyloroplasty, both H-M pyloroplasty and Finney’s pyloroplasty were better than laparoscopic gastro-jejunostomy.

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.

Initial Experience with Endoscopic Pyloromyotomy, with Description and Video of Technique

BackgroundGastric per oral endoscopic myotomy (G-POEM) is a recently developed incisionless procedure to address gastroparesis. It has been previously described to treat medical and postsurgical gastroparesis. The present study is a case series of patients undergoing G-POEM for a variety of indications, both elective and urgent. MethodsIRB approval was obtained for retrospective review of a prospectively collected database including patients who underwent G-POEM during a 1.5-year period. Using an upper endoscope, a mucosotomy is made 2 cm proximal to the pylorus on the anterior surface of the stomach. A submucosal tunnel is made to the pylorus muscle, which is completed incised. When possible, Endoflip® was used to evaluate pyloric distensibility before and after the myotomy. Patient demographic factors, additional procedures, and other follow-up were collected by chart review. Elective cases were offered repeat gastric emptying study at 6 months. ResultsThere were 17 patients available for review. The procedure was technically completed in all cases. There was one gastric perforation recognized on postoperative day two that was addressed with laparoscopy and omental patch. Median length of stay was zero days, and 13/17 (76%) of patients experienced symptomatic relief. Pyloric distensibility significantly decreased intraoperatively from 5.6 (± 1.7) to 10.8 (± 5.0) cm2/mmHg (p = 0.002). ConclusionThis limited case series demonstrates G-POEM to be a versatile procedure able to address gastroparesis in a variety of settings. Success rates are congruent with previously published reports, and one serious complication was able to be addressed laparoscopically. Endoflip® was able to verify a successful myotomy intraoperatively. This procedure is an attractive alternative to less effective non-invasive treatments and a more invasive laparoscopic pyloroplasty.

192 – Simultaneous Laparoscopic Pyloroplasty and Gastric Stimulator Insertion is an Effective Palliative Option for Treatment of Medically Refractory Gastroparesis

192 – Simultaneous Laparoscopic Pyloroplasty and Gastric Stimulator Insertion is an Effective Palliative Option for Treatment of Medically Refractory Gastroparesis

Hybrid endoluminal stapled pyloroplasty: an alternative treatment option for gastric outlet obstruction syndrome.

Gastroparesis is a rapidly increasing problem with sometimes devastating consequences. While surgical treatments, particularly laparoscopic pyloroplasty, have recently gained popularity, they require general anesthesia, advanced skills, and can lead to leaks. Peroral pyloromyotomy is a less invasive alternative; however, this technique is technically demanding and not widely available. We describe a hybrid laparo-endoscopic collaborative approach using a novel gastric access device to allow endoluminal stapled pyloroplasty as an alternative treatment option for gastric outlet obstruction. Under general anesthesia, six pigs (mean weight 33kg) underwent endoscopic placement of intragastric ports using a technique similar to percutaneous endoscopic gastrostomy. A 5mm laparoscope was used for visualization. A functional lumen imagine probe was used to measure the cross-sectional area (CSA) and diameter of the pylorus before, after, and at 1week after intervention. Pyloroplasty was performed using a 5mm articulating laparoscopic stapler. Gastrotomies were closed by endoscopic clips, endoscopic suture, or combination. After 6-8days, a second evaluation was performed. At the end of the protocol, all animals were euthanized. Six pyloroplasties were performed. In all cases, this technique was effective in achieving significant pyloric dilatation. The median pre-pyloroplasty pyloric diameter (D) and cross-sectional area (CSA) were 8mm (4.9-11.6mm) and 58.6mm2 (19-107mm2), respectively. After the procedure, these values increased to 13.41mm (9.8-17.6mm) and 147.7mm2 (76-244mm2), respectively (p = 0.0152). No important intraoperative events were observed. Postoperatively, all animals did well, with adequate oral intake and no relevant complications. At follow-up endoscopy, all incisions were healed and the pylorus widely patent. Hybrid endoluminal stapled pyloroplasty is a feasible, safe, and effective alternative method for the treatment of gastric outlet obstruction syndrome.

Not Cancer … but Pyloric Stenosis in a 69-year-old?

Idiopathic hypertrophic pyloric stenosis (IHPS) is most commonly reported in infants with rates ranging from 0.25% to 0.8% of all live births. Adult IHPS is rare and only 200 cases have been reported in the literature. We present a patient in her late-sixties with cachexia and severe malnutrition with a gastric mass visualized on CT that initially was concerning for malignancy and was subsequently diagnosed with IHPS. A 69-year-old woman, with limited healthcare exposure, was admitted to the hospital with weight loss, anorexia, fatigue, severe malnutrition (BMI 13.7), severe anemia, elevated inflammatory markers (CRP >200, ESR 76), and hypotension leading to a traumatic fall. She was an active smoker with a 51 pack-year history and consumed 2 alcoholic drinks daily. She denied history of acid reflux and had no known history of H. pylori. Rheumatologic workup was negative. Given lack of medical history and severe cachexia, CT chest and abdomen were obtained as there was concern for malignancy. A right ovarian cyst and cystic lesion in the head of pancreas was initially reported and were subsequently determined to be benign. Due to her continued inability to tolerate oral intake, EGD was performed which revealed gastric stenosis with pinhole opening at the pylorus and no visible ulcerations. Biopsy revealed reactive gastropathy and foveolar hyperplasia without inflammation. Review of CT did show evidence of hypertrophy around the pyloric sphincter. She was endoscopically dilated and was able to advance her diet with careful monitoring for refeeding syndrome. At her three-month follow-up visit, she was tolerating general diet, was slowly gaining weight, and her anemia had resolved. This case demonstrates an uncommon case of adult-onset IHPS causing severe malnutrition and cachexia. Most cases of hypertrophic pyloric stenosis are diagnosed in early infanthood. Initial management often includes nasogastric tube placement to remove gastric contents. Gastrectomy, pyloromyotomy, and pyloroplasty have been recommended for surgical management with laparoscopic pyloroplasty as the preferred intervention due to its favorable safety profile. Dilation is another acceptable treatment option; however has a high recurrence rate of stenosis.Figure: Computed tomography, coronal view of pyloric stenosis in a 69-year-old female.

Modified Laparoscopic Pyloroplasty During Laparoscopic Splenectomy and Azygoportal Disconnection for the Prevention of Postoperative Gastroparesis.

Gastroparesis is a common complication after splenectomy and azygoportal disconnection, remaining a chronic debilitating disorder with considerable treatment challenges. To minimize postoperative gastroparesis, we have developed a new modified laparoscopic pyloroplasty (LP) technique for use during laparoscopic splenectomy and azygoportal disconnection (LSD). We retrospectively evaluated the outcomes of 31 cirrhotic patients with portal hypertensive bleeding and secondary hypersplenism who underwent synchronous LSD with modified LP (n = 14) or LSD without modified LP (n = 17) between January 2015 and August 2015. Perioperative variables were compared. LSD with and without modified LP were successful in all patients. Operation time was significantly longer for LSD with modified LP than LSD without modified LP ( P = .001). However, the LSD with modified LP group had significantly reduced incidences of bloating 1 month postoperatively ( P < .05), nausea ( P < .05), and bloating ( P < .05) 3 months postoperatively, gastric retention 3 months postoperatively ( P < .0001), and prokinetic use at 1 month ( P = .009) and 3 months postoperatively ( P < .05) compared with the LSD without modified LP group. Gastric emptying scintigraphy showed that the mean time required to empty 50% of the ingested meal was significantly shorter in the LSD with modified LP group than in the LSD without modified LP group at 3 months postoperatively (74.3 ± 19.1 vs 261.7 ± 61.0 minutes, P < .0001). Modified LP during LSD was feasible, effective, and safe, and significantly reduced short-term symptoms of postoperative gastroparesis.

Novel Diet, Drugs, and Gastric Interventions for Gastroparesis.

This review of the pathophysiologic basis for gastroparesis and recent advances in the treatment of patients with gastroparesis shows that there are several novel approaches to advance treatment of gastroparesis including diet, novel prokinetics, interventions on the pylorus, and novel forms of gastric electrical stimulation. The field of gastroparesis is likely to advance with further studies, with help from a guidance document from the Food and Drug Administration on gastroparesis, and with recent approval of the stable isotope gastric emptying test to ensure eligibility of participants in multicenter trials. Clinical experience and a formal, randomized, controlled trial provide insights on optimizing dietary interventions in patients with gastroparesis. This review addresses the biologic rationale of these different treatments, based on known physiology and pathophysiology of gastric emptying. The novel medications include the motilin agonist, camicinal; 5-HT4 receptor agonists, such as velusetrag; and the ghrelin agonist, relamorelin. New approaches target pylorospasm by stent placement, endoscopic pyloric myotomy, or laparoscopic pyloroplasty. These approaches offer the opportunity to achieve more permanent reduction of resistance to flow at the pylorus over the intrapyloric injection of botulinum toxin, which typically has to be repeated every few months if it is efficacious. A novel device, deployed in porcine stomach, involved per-endoscopic electrical stimulation. These promising approaches require formal, randomized, controlled trials and deployment in patients. The presence of concomitant antral hypomotility may be a significant factor in the responsiveness to interventions at the pylorus.

Laparoscopic pyloroplasty is a safe and effective first-line surgical therapy for refractory gastroparesis.

Surgical options for symptomatic delayed gastric emptying include gastric stimulator implantation, subtotal gastrectomy, and pyloroplasty. Pyloroplasty has been shown to improve gastric emptying yet is seldom described as a primary treatment for gastroparesis. We present a single-institution experience of laparoscopic Heineke-Mikulicz pyloroplasty (LP) as treatment for gastroparesis. A prospective foregut surgery database was queried for LP over a 5-year period. Charts were reviewed for indications, complications, symptom score, and outcomes. Gastroparesis was defined by (1) abnormal gastric emptying study, (2) endoscopic visualization of retained food after prolonged NPO status, or (3) clinical symptoms suspicious of vagal nerve injury following complex re-operative foregut surgery. Results were analyzed using a paired T test and single-factor ANOVA. One hundred and seventy-seven LP patients were identified and reviewed. One hundred and five had a concurrent fundoplication for objective reflux. There were no intraoperative complications or conversions to laparotomy. Overall morbidity rate was 6.8% with four return to OR and two confirmed leaks (1.1% leak rate). Average length of stay was 3.5 days, and readmission rate was 7%. Eighty-six percent had improvement in GES with normalization in 77%. Gastric emptying half-time decreased from 175 ± 94 to 91 ± 45 min. Nineteen patients (10.7%) had subsequent surgical interventions: gastric stimulator implantation (12), feeding jejunostomy and/or gastrostomy tube (6), or subtotal gastrectomy (4). Symptom severity scores for nausea, vomiting, bloating, abdominal pain, and early satiety decreased significantly at 3 months. Laparoscopic pyloroplasty improves or normalizes gastric emptying in nearly 90% of gastroparesis patients with very low morbidity. It significantly improves symptoms of nausea, vomiting, bloating, and abdominal pain. Some patients may go on to another surgical treatment for GP, but it remains a safe and less invasive alternative to a subtotal gastrectomy in these clinically challenging patients.

Pyloroplasty for Refractory Gastroparesis

Gastroparesis is a chronic gastric motility disorder in which the pathophysiology mimics a postvagotomy state. Pyloroplasty is beginning to emerge as a successful drainage procedure for refractory gastroparesis. Here we report our experience using pyloroplasty in the surgical management of diabetic and nondiabetic gastroparesis. A retrospective study was performed of 46 patients undergoing pyloroplasty for refractory gastroparesis from January 2010 through December 2013. Gastric emptying scintigraphy and the Gastroparesis Cardinal Symptom Index were assessed pre- and postoperatively. Laparoscopic pyloroplasty was performed in 42 patients, open pyloroplasty in three, and one patient was converted from laparoscopic to open pyloroplasty. Studies were repeated during the six to 12 month postoperative interval. The postoperative gastric emptying scintigraphy improved in 90 per cent of patients and normalized in 60 per cent. Postoperative T½ was significantly reduced (P = 0.001) as was four-hour retention (P < 0.001). The Gastroparesis Cardinal Symptom Index showed statistically significant reduction in symptom severity for all nine categories (P < 0.0005) as well as total symptom score (P < 0.005). No patients developed dumping syndrome. Pyloroplasty is a highly effective therapy for refractory gastroparesis, offering significant reduction in symptom severity, improvement in quality of life, and acceleration of gastric emptying.

Adult Idiopathic Hypertrophic Pyloric Stenosis

Introduction: Adult idiopathic hypertrophic pyloric stenosis (AIHPS) is a rare entity. The most common clinical symptom is abdominal distention relieved by vomiting. There are several treatment modalities for relief of the pyloric obstruction. Case Description/Technique: A 43-year-old woman presented with a long history of epigastric pain, nausea, vomiting, and bloating, which appeared to be caused by functional dyspepsia. She also reported severe postprandial epigastric pain that was thought to be secondary to peptic ulcer disease (PUD). She had lost 7 kg, leading to a poor nutritional status. Further investigation by upper gastrointestinal endoscopy demonstrated moderate stenosis at the pylorus. After discussion, she elected to undergo laparoscopic Heineke-Mikulicz pyloroplasty. The patient was placed supine, and entrance into the peritoneal cavity was obtained with a 5-mm optical trocar. The pylorus was clearly identified and was visibly thickened. Two 2-0 silk stay sutures were placed. Gastrotomy was made with a harmonic scalpel, and the pylorus was cut. The pylorus was reconstructed horizontally by using the Heineke-Mikulicz technique. Finally, a second layer of interrupted 2-0 silk sutures was placed. Discussion: The etiology of AIHPS remains unclear. In a case report, Zarineh et al. classified AIHPS into two main types: primary and secondary. Several factors are important in establishing the diagnosis. The approaches include endoscopic dilation, gastrojejunostomy, partial gastrectomy, and pyloromyotomy with or without pyloroplasty. Despite the technical difficulty, operative procedures such as the Heineke-Mikulicz pyloroplasty have shown favorable results. Currently, laparoscopic pyloroplasty may represent a reasonable, less invasive option for this rare condition.

腹腔鏡補助下選択的近位迷走神経切離術が奏効した十二指腸潰瘍再発の１例

腹腔鏡補助下選択的近位迷走神経切離術が奏効した十二指腸潰瘍再発の１例