Peroral Endoscopic Pyloromyotomy Research Articles

Gastric Peroral Endoscopic Pyloromyotomy for Infants With Congenital Hypertrophic Pyloric Stenosis: Ready for Prime Time?

1Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA. Correspondence: Petar Mamula, MD. E-mail: [email protected].

Gastric peroral endoscopic pyloromyotomy for the treatment of congenital hypertrophic pyloric stricture in an infant with a self-made bite block.

Gastric per-oral endoscopic myotomy (G-POEM) is reported to be a promising treatment for refractory gastroparesis, on the other hand, it is also an effective treatment for congenital hypertrophic pyloric stenosis (CHPS). Here, we want to report a case in which G-POEM was performed in an infant with CHPS.

Gastric peroral endoscopic pyloromyotomy (G-POEM) in patients with refractory gastroparesis: a review.

Gastric peroral endoscopic pyloromyotomy (G-POEM or POP) is an endoscopic therapeutic modality for treatment of refractory gastroparesis. Since the first case reported in 2013, there are more than 200 papers published on G-POEM. In this narrative review, we summarize the short-term and long-term outcomes and review other important studies. The technical success rate is 100% and the short-term (within 1 year) success rate is about 50-80%. The procedure time is between 50 and 70 min while the average length of hospital stay was 2-3 days. The adverse event rate was around 10%. Few patients need further intervention. Three studies showed that at the 4-year follow-up, the response to G-POEM was durable, but there was a yearly recurrence rate of 13% or more. Redo G-POEM is feasible and can be of benefit for some patients. Most of the studies showed that long duration of illness is associated with poor outcomes. However, reliable predictors for successful outcomes are still unknown. Current literature indicates G-POEM is superior to gastric electric stimulator and surgical pyloroplasty. Endoflip has been used at G-POEM to predict the outcome, but the result is very preliminary. A recent sham study confirms the short-term efficacy of G-POEM. G-POEM is safe and about 50% of patients can be discharged to home on the same day. G-POEM allows for direct biopsy of the gastric muscle, which is the location of the pacemaker cells, the interstitial cells of Cajal; therefore, G-POEM may provide a new path for further research on the pathogenesis of gastroparesis.

Endoscopic clips versus overstitch suturing system device for mucosotomy closure after peroral endoscopic pyloromyotomy (G-POEM): a prospective single-center study.

G-POEM is an emerging method for treatment of severe gastroparesis. Safe mucosal closure is necessary to avoid adverse events. The aim of this study was to compare the efficacy of two closure methods: clips and endoscopic suturing (ES) after G-POEM. We performed a single center, prospective study. The closure method was assigned at the discretion of an endoscopist prior to the procedure. The main outcome was the proportion of subjects with successful closure. Unsuccessful closure was defined as a need for a rescue method, or a need for an additional intervention or incomplete closure-related adverse events. Secondary outcomes were the easiness of closure (VAS score 1 = very difficult, 10 = easy), closure time, and cost. A total of 40 patients [21 female; mean age, range 47.5; (20-74)] were included; 20 received ES and 20 clips [mean number of clips 6; range (4-19)]. All 20 patients with ES (100%, 95% CI 84-100%) and 18 patients with clips (89%, 95% CI 70-97%) had successful closure (p = 0.49). One patient needed a rescue method (KING closure) and the other patient an additional clipping on POD1. Closure with clips was quicker [mean time 9.8 (range 4-20) min vs. 14.1 (5-21) min; p = 0.007] and cheaper [mean cost 807 USD (± 402) vs. 2353 USD (± 145); p < 0.001]. Endoscopist assessed the easiness of ES and clips as comparable [mean VAS, range 7.5 (3-10) (ES) vs. 6.9 (3-10) (clips); p = 0.3]. Both ES and clips are effective methods for mucosal closure in patients undergoing G-POEM. However, centres using clips should have a rescue closure method available as clips may fail in some patients. Closure with ES is more costly than with clips.

A New Paradigm Shift in Gastroparesis Management.

Gastroparesis, once regarded as a rare disease, is difficult to diagnose and challenging to treat; there were many breakthrough advances in the 2010s, shifting the paradigm of the understanding of this complex entity and its management. Similar to diabetes, its increasing prevalence reflects increased accessibility to diagnostic modalities and suggests that gastroparesis was underacknowledged in the past. Major developments in the three main aspects of the disease include the discovery of smooth muscle cells, interstitial cells of Cajal, PDGFRα+ cells syncytium, rather than interstitial cells of Cajal alone, as the main gastric pacemaker unit; the development of validated point-of-care diagnostic modalities such as a wireless motility capsule, the carbon 13-labeled breath test, and impedance planimetry; and the introduction of novel minimally invasive therapeutic options such as newer pharmacologic agents and gastric peroral endoscopic pyloromyotomy. All aspects of these advances will be discussed further in this review.

Endoscopic findings do not predict per-oral pyloromyotomy (POP) response.

Gastroparesis is a life-altering diagnosis caused by the stomach's inability to function in the absence of a mechanical obstruction. The primary causes are idiopathic, diabetic, and postoperative. Our first-line treatment for medical refractory gastroparesis is the endoscopic per-oral pyloromyotomy (POP) procedure. Predicting clinical response cost effectively remains elusive. All patients who underwent a POP procedure at our institution by a single surgical endoscopist from January 1, 2019 to June 30, 2020 were retrospectively reviewed. All endoscopic data were prospectively collected. The patients were followed by a survey including the Gastroparesis Cardinal Symptom Index (GCSI) and other relevant postoperative measures. The primary endpoint was clinical response defined as ≥ 1.0 decrease in the GCSI from preoperative to the time of survey. Secondary outcome was normalization of the gastric emptying study (GES). Our patient population is 85% female and has an average age of 44.8years. The diagnosis of gastroparesis is 71% iatrogenic, 19% postoperative, and 10% diabetic. On endoscopy, 30% had bile in the stomach and 65% had any degree of pylorospasm. The primary outcome measure of clinical response was 39% at an average of 697 ± 151days post-POP, but 66% of patients attested to an improvement in their symptoms. Of 68 postoperative gastric emptying studies 50% normalized at an average of 145 ± 98days. Following univariate and multivariate analyses of preoperative data and endoscopic findings, there were no significant predictors of clinical response. A preoperative GCSI ≥ 2.6 trends toward significance (OR 6.87, p = 0.058). Endoscopic findings at the time of POP do not correlate with clinical response. The GCSI model currently used to measure clinical response may not accurately capture the full clinical picture. The long-term durability of endoscopic myotomy to treat medical refractory gastroparesis needs to be studied further to improve patient selection.

Per-Oral Endoscopic Pyloromyotomy in a Patient with History of Sleeve Gastrectomy: A Promising Intervention for Gastroparesis?

Per-Oral Endoscopic Pyloromyotomy in a Patient with History of Sleeve Gastrectomy: A Promising Intervention for Gastroparesis?

Quantification of Interstitial Cells of Cajal in the Gastric Muscle of Patients with Gastroparesis at Per-Oral Endoscopic Pyloromyotomy: A Novel Approach for Future Research in Pathogenesis of Gastroparesis.

The role of Interstitial Cells of Cajal (ICC) in the pathogenesis of gastroparesis has been suggested by previous studies due to their involvement in the transmission of neuronal signaling to the smooth muscles of the GI tract. However, studies have been limited by the inability to obtain a gastric muscle sample, since routine endoscopy can only biopsy the mucosa. We present a new technique of muscle biopsy during per-oral endoscopic pyloromyotomy (GPOEM), a novel endoscopic procedure for treatment of gastroparesis. All enrolled patients had diagnosed gastroparesis and had biopsies of the muscular layer at the antrum/pylorus during POEM. All GPOEM procedures took place from August 2019 to December 2019. Various demographic, disease-related, and procedure-related data were collected from chart review. ICC in the biopsy specimen was examined and quantitated. Through this method, we readily expose the gastric muscle of 21 patients through dissection of a gastric submucosal tunnel during GPOEM and provide reliable muscle sample for ICC quantification. Average number of ICC were higher in clinical responders (88 ICC ± 63 vs. 39 ICC ± 24, p = 0.02), defined as those who experienced significant improvement in nausea and vomiting symptoms after GPOEM. This study provides a reliable novel biopsy method for safely biopsy gastric muscle for quantitating the number of gastric ICC in patients with gastroparesis. The number of ICC may be related to the outcome of GPOEM therapy. However, further studies with larger number of patients are needed to confirm the results.

Clip-anchoring technique: a fast, cheap, and efficient way to close a gastric peroral endoscopic pyloromyotomy tunnel.

Clip-anchoring technique: a fast, cheap, and efficient way to close a gastric peroral endoscopic pyloromyotomy tunnel.

Endoscopic pyloromyotomy is feasible and effective in improving post–lung transplant gastroparesis

ObjectivesGastroparesis is a debilitating and difficult to manage problem that has been reported in 20% to 90% of lung and heart-lung transplant recipients. The primary objective was to evaluate the safety and clinical effectiveness of per-oral endoscopic pyloromyotomy in relieving gastroparesis after lung transplant. Secondary objectives evaluated the effect of per-oral endoscopic pyloromyotomy on gastroesophageal reflux and allograft function. MethodsFifty-two lung transplant recipients underwent per-oral endoscopic pyloromyotomy for refractory gastroparesis. Gastroparesis was assessed by a pre–per-oral endoscopic pyloromyotomy and post–per-oral endoscopic pyloromyotomy radionuclide gastric emptying test and Gastroparesis Cardinal Symptom Index. Secondary outcomes included 90-day complications, gastroesophageal reflux as measured by pH testing, and longitudinal spirometry measurements. ResultsMedian time from lung transplant to per-oral endoscopic pyloromyotomy was 10.5 months. Twenty-eight patients had prior pyloric botulinum injection with either no improvement or relapse of symptoms. Post–per-oral endoscopic pyloromyotomy gastric emptying tests were available for 32 patients and showed a decrease in median gastric retention at 4 hours from 63.5% pre–per-oral endoscopic pyloromyotomy to 5.5% post–per-oral endoscopic pyloromyotomy (P < .0001). Complete normalization of gastric emptying time was noted in 19 patients. Gastroparesis Cardinal Symptom Index score significantly improved after per-oral endoscopic pyloromyotomy (median, 23-3.5; P < .0001). Post–per-oral endoscopic pyloromyotomy pH testing showed improved or stable DeMeester score in all patients except 1. Graft function (forced expiratory volume in 1 second) remained stable 1 year after per-oral endoscopic pyloromyotomy. ConclusionsThe improvements in symptom score and radionuclide imaging observed in this uncontrolled study suggest that per-oral endoscopic pyloromyotomy is an effective strategy in the lung transplant population and can be performed with minimal morbidity.

Navigational tunnel technique for gastric peroral endoscopic pyloromyotomy: getting straight to the point (pylorus).

Background and AimsGastric peroral endoscopic pyloromyotomy (G-POEM) is emerging as a treatment option for patients with gastroparesis. The most technically difficult part of the procedure is creating a submucosal tunnel in the gastric antrum, which can be directionally challenging. We describe a novel navigational tunneling method that guides submucosal dissection in the direction of the pylorus and helps to identify the pyloric landmarks.MethodsConsecutive patients from September to December 2020 who underwent G-POEM for symptomatic gastroparesis were included. All cases were confirmed by prolonged gastric emptying study. The navigational tunnel technique was performed as follows: (1) mucosal cautery markings were made to outline the tunnel starting 3 to 4 cm proximal to the pylorus, (2) submucosal injection was done at the level of the pylorus and extended backward to the incision point, and (3) submucosal dissection was carried out after the prior submucosal injection straight to the pylorus.ResultsSix patients with gastroparesis underwent G-POEM with the navigational tunneling technique. The average time for submucosal injection was 2 minutes and 42 seconds, and the average tunnel time was 15 minutes and 36 seconds. There were no adverse events. All patients reported significant improvement (50%-85%) in symptoms.ConclusionsThis novel navigational tunneling technique appears to guide and facilitate G-POEM by providing a visual path for submucosal dissection straight to the pylorus. It may increase efficiency, decreasing the need to repeatedly exit the tunnel to check direction and preventing nonproductive wandering. It may also help identify the pyloric ring within the tunnel.

Beyond Metoclopramide for Gastroparesis

Beyond Metoclopramide for Gastroparesis

ID: 3527213 THIRD SPACE ENDOSCOPY AFTER FORMAL ENDOSCOPY ADVANCED FELLOWSHIP TRAINING IN THE US: ONE YEAR LINEAR FOLLOW UP OF INDEPENDENT PRACTICE

Third space endoscopy includes peroral endoscopic myotomy (POEM) and gastric peroral endoscopic pyloromyotomy (GPOEM). Very few advanced endoscopy fellowships offer comprehensive training in third space endoscopy in addition to ERCP and EUS, given the risk associated with these procedures. Multiple studies have reported the learning curve for POEM. We followed a single trainee experience following formal third space endoscopy training.

Per Oral Pyloromyotomy for Treatment of Gastroparesis in a Pediatric Patient

Per Oral Pyloromyotomy for Treatment of Gastroparesis in a Pediatric Patient

Refeeding syndrome: a fatal adverse event of gastric peroral endoscopic pyloromyotomy

A 61-year-old woman with a history of chronic obstructive pulmonary disease and body mass index of 24 presented with recurrent hospital admissions for intractable nausea, vomiting, and weight loss of 40 pounds over the previous 3 months. The results of an extensive workup including upper and lower endoscopy, and CT of the chest, abdomen, and pelvis, were negative. A gastric emptying study demonstrated severe idiopathic gastroparesis. Medical treatment with metoclopramide (Reglan), erythromycin, and antiemetics was unsuccessful in controlling the symptoms.

Gastric Peroral Endoscopic Myotomy: A Specific Learning Curve.

Gastric peroral endoscopic pyloromyotomy (G-POEM) is a novel option for patients with gastroparesis. It involves submucosal tunneling across the pylorus, followed by pyloromyotomy, and subsequent closure of the endoscopic tunnel. The aim of this study was to determine the learning curve for G-POEM. Consecutive patients undergoing G-POEM by a single operator were included from a prospective registry over 2 years. Demographics, procedure info, postprocedure follow-up data, and adverse events were collected. Nonlinear regression and cumulative sum control chart analyses were conducted for the learning curve. Clinical outcomes were improvement in Gastroparesis Cardinal Symptom Index score and gastric emptying scintigraphy. Thirty-six patients were included (16.7% M, mean age 46 y). The majority had idiopathic gastroparesis (n=16, 44%), with the remaining having diabetes (n=5, 17%), postsurgical (n=10, 28%), or other (n=4, 11%). Technical success was achieved in 35 of 36 (97%). There was a significant reduction in the total Gastroparesis Cardinal Symptom Index score (2.09 units, P<0.00001) and a significant reduction in postoperative gastric emptying scintigraphy (82.44 mins, P<0.00001). Mean follow-up was 15 months (SD, 1.05). Median procedure time was 60.5 minutes (range, 35 to 136). Cumulative sum control chart shows 60-minute procedure was achieved at the 18th procedure. Procedure durations further reduced with consequent procedures with the last 3 being 45 minutes, thus demonstrating continued improvement with ongoing experience (nonlinear regression P<0.0001). Endoscopists experienced in G-POEM are expected to achieve a reduction in procedure time over successive cases, with efficiency reached at 60.5 minutes and a learning rate of 18 cases with continuing improvement.

Gastric peroral endoscopic pyloromyotomy for decompensated gastroparesis: comprehensive motility analysis in relation to treatment outcomes.

Background and study aims There are no reliable data to predict which patients with gastroparesis (GP) would benefit the most from gastric peroral endoscopic pyloromyotomy (G-POEM). The aim of the present study was to assess whether antro-duodenal motility patterns and pyloric distensibility can predict the outcome of G-POEM in patients with decompensated GP. Patients and methods In an open-label study, patients with GP and refractory symptoms were eligible for treatment with G-POEM if treatment attempts according to a standardized stepwise protocol had failed. Baseline assessment included Gastroparesis Cardinal Symptom Index (GCSI), C13-octanoic gastric emptying breath test and high-resolution antro-duodenal manometry. Pyloric distensibility using EndoFlip measurements was assessed at baseline and 3 months after the procedure. Explorative analyses were performed on potential predictors of response using logistic regression analyses. Results Twenty-four patients with decompensated GP underwent G-POEM. At baseline, 78.3 % and 61.9 % of patients showed antral hypomotility and neuropathic motor patterns, respectively. The technical success rate was 100 % (24/24). Mean GCSI improved significantly at 3, 6, and 12 months after G-POEM ( P = 0.01). Median distensibility index (DI) improved significantly as compared with baseline (7.5 [6.9;11.7] vs. 5.3[3.1;8.1], P = 0.004). A significant correlation was found between clinical response at 6 months and pyloric DI improvement ( P = 0.003). No potential predictors of clinical response after G-POEM could be identified in an explorative analysis. Conclusions G-POEM improved pyloric distensibility patterns in patients with decompensated GP. Clinical response at 6 months after G-POEM was associated with pyloric distensibility improvement. However, no potential predictors of response could be identified from either antro-duodenal motility patterns or pyloric distensibility.

Real-time intraoperative functioning lumen imaging probe during endoscopic per-oral pyloromyotomy (pop)

BackgroundEndoscopic per-oral pyloromyotomy (POP) has emerged as a safe and effective first line option in medically refractory gastroparesis. Determining the appropriate extent of the pyloromyotomy continues to present a challenge as there are no standardized tools for measuring changes in pyloric distensibility during the procedure. The objective of this study was to evaluate the utility of using impedance planimetry with endoscopic functional luminal imaging probe (FLIP) to measure changes in pyloric distensibility after POP, and to compare these changes with improvement in symptoms and objective gastric emptying.MethodsPatients with medically refractory gastroparesis underwent POP with FLIP measurements of the pylorus (EndoFLIP®, Medtronic, Fridley MN). FLIP measurements, as well as changes in symptoms measured by the validated gastroparesis cardinal symptom index (GCSI) and scintigraphic gastric emptying studies (GES), were evaluated before and after POP.ResultsA total of 14 patients underwent measurement with FLIP during POP, 12 of whom had pre- and post-POP measurements. Mean pyloric diameter increased by 1.4 mm, from 13.9 mm to 15.3 mm (p = 0.0012). Mean distensibility index increased from 6.2 mm2/mmHg to 9.1 mm2/mmHg (p = 0.0074). Successful division of the pylorus was achieved in 100% of patients with a mean operative time of 36 min and no perioperative complications. The mean length of stay was 0.7 days (0–3 days). Post-POP mean GCSI score improved from 2.97 to 2.28 at a mean follow-up time of 27 days (p < 0.001). Objective improvement in gastric emptying was observed in 80% of patients with scintigraphic GES, with mean four-hour retention decreasing from 46.3% to 32.4% (p < 0.007).ConclusionsFLIP is a safe and feasible tool to provide objective measurements during POP. Larger cohorts with longer follow-up are required to determine if measured improvements in pyloric diameter and distensibility are predictive of sustained improvements in GCSI and GES.

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.

Teaching peroral endoscopic pyloromyotomy (POP) to practicing endoscopists: An “into-the-fire” approach to simulation

BackgroundPeroral endoscopic pyloromyotomy, or gastric peroral endoscopic myotomy, is a novel endoscopic procedure for the treatment of refractory gastroparesis. We present a simulation-based curriculum using an “into-the-fire” approach with hands-on pre- and post-tests to teach this procedure. MethodsSix, 1-day peroral endoscopic pyloromyotomy courses were taught by an expert surgical endoscopist in 2018 to 2019. The curriculum is composed of a series of pretraining tests, lectures, mentored hands-on instruction, and post-training tests using porcine models. Both pre- and post-testing included a confidence survey, a knowledge-based written test, and a specific assessment form for the peroral endoscopic pyloromyotomy procedure. Participants’ scores were analyzed using paired t tests. ResultsTwenty-eight practicing physicians participated. After completing the curriculum, participants had improved confidence scores (10.5 ± 5.2 vs 19.4 ± 3.6; P < .001), written test scores (6.8 ± 1.6 vs 8.0 ± 1.1; P < .001), and hands-on performance scores (23.6 ± 3.4 vs 29.3 ± 1.4; P < .001) with marked improvement in all components of the peroral endoscopic pyloromyotomy procedure. Postcourse surveys showed 93% of participants had performed or intended to perform the peroral endoscopic pyloromyotomy procedure within the next year. ConclusionOur simulation curriculum with an into-the-fire approach to teach peroral endoscopic pyloromyotomy is effective in improving practitioner knowledge, confidence, and technical skills, leading to an increase in the adoption of this procedure.