Peroral Pyloromyotomy Research Articles

PYLORIC IMPEDANCE PLANIMETRY DURING ENDOSCOPIC PER-ORAL PYLOROMYOTOMY (POP) GUIDES MYOTOMY EXTENT

BACKGROUNDPer-oral pyloromyotomy (POP), also known as gastric per-oral pyloromyotomy (G-POEM), is the first-line endoscopic intervention for medically refractory gastroparesis. We sought to assess the value of pyloric impedance planimetry using functional luminal imaging probe (FLIP) during POP. METHODSPatients undergoing POP were retrospectively reviewed from October 2019-February 2024. FLIP measurements, symptoms measured by the gastroparesis cardinal symptom index (GCSI), and gastric emptying scintigraphy (GES) were evaluated before and after POP. RESULTSThirty-five patients (29 (82.9%) female, 51.3 (38.4, 60.9) years old, BMI 29.26 (25.46, 32.56kg/m2) underwent POP. Twenty-three patients had pre- and post-POP FLIP measurements. Median pyloric diameter increased from 14.4 (12, 16) to 16 (14.8, 18) mm (S=116.5, p<0.0001). Median distensibility index (DI) increased from 4.85 (3.38, 6) to 8.45 (5.25, 11) mm2/mmHg (S=112, p<0.0001). Management changed based on FLIP values for 5 patients (21.7%) prompting additional myotomy. At 18 (12.8, 47.8) days post-procedure, median GCSI score decreased from 3.33/5 (2.56, 4.12) preoperatively to 2/5 (1, 2.89) postoperatively (S=-193, p<0.001). At 136 (114, 277) day follow-, improvement in GCSI score persisted with a median score of 2.44/5 (1.44, 3.67) (S=-61, p=0.021). Median retention at 4hours on GES decreased from 29% (16.5, 52) to 19.5% (5.75, 35.3) at 97 (88, 130) days post-procedure (S=-108, p=0.0038). There was 75% improvement and 40% normalization of objective gastric emptying (n=26). Greater increase in diameter after pyloromyotomy correlated to a greater decrease in four-hour gastric retention (r=-0.4886, p=0.021). CONCLUSIONPOP with FLIP resulted in clinical and radiographic improvement in patients with gastroparesis. FLIP measurements guided myotomy extent, changing management in 21.7% of patients and were correlated with gastric emptying, demonstrating its distinct utility in treatment of gastroparesis.

Initial experience and outcomes of per oral pyloromyotomy for the treatment of refractory gastroparesis.

Gastroparesis can be a debilitating disease process for which durable treatment options are lacking. While dietary changes and pharmacotherapy have some efficacy, symptoms frequently recur and some patients progress to needing supplemental enteral feeding access. Per oral pyloromyotomy (POP) has been shown to be a durable minimally invasive treatment option for refractory gastroparesis with a low side effect profile, and therefore has been performed at this institution for the past 6 years. This was a retrospective case series of all patients who underwent a POP at a single institution over a 6-year period (2018-2023). Patient demographics, preoperative symptomatology and subsequent workup, postoperative complications, and symptom recurrence were collected and analyzed. There were 56 patients included in the study. There was a 1.8:1 female:male ratio. The average patient age was 56 years old (range 23-85). The average duration of symptoms was 1-3 years. Thirty-eight percent of patients had undergone previous endoscopic therapy for gastroparesis (pyloric botox injection or pyloric dilation) and 16% of patients underwent multiple endoscopic therapies. Twenty-nine percent of patients were on a medication for gastroparesis. Past surgery was the most common gastroparesis etiology for POP (50% of patients). Diabetes (23%) and idiopathic (19%) were the other most common gastroparesis etiologies for POP. Nausea was the most common symptom at first follow-up (30%) but these patients continued to improve with 14% of patients continuing to endorse nausea at 6 months. Twenty-seven percent of patients developed symptom recurrence. Forty percent of patients with symptom recurrence underwent a repeat endoscopic or surgical therapy. In this present study, POP leads to durable results in approximately 75% of patients with minimal complications. Furthermore, the majority of patients who do develop symptom recurrence do not require additional gastroparesis interventions.

S1264 Gastric Per-Oral Pyloromyotomy With Monitored Anesthesia Care Is Safe and Practicable: A Pilot Study

S1264 Gastric Per-Oral Pyloromyotomy With Monitored Anesthesia Care Is Safe and Practicable: A Pilot Study

Response to botulinum toxin may predict response to peroral pyloromyotomy in patients with gastroparesis.

We performed a retrospective cohort study to assess whether symptomatic improvement after BTI predicts a response to POP. We included 119 patients who had undergone both BTI and POP at Cleveland Clinic Ohio or Cleveland Clinic Florida from January 2016 to September 2019. 65.5 % of patients had symptomatic improvement after BTI. Gastroparesis Cardinal Symptom Index (GCSI) scores were available for 74 patients, with 64 % achieving a response to POP, defined as a decrease in mean GCSI ≥ 1. In multivariable analysis, response to BTI (odds ratio [OR] 7.7 [95 %CI 2.2-26.1]) and higher pre-POP GCSI score (OR 2.3 [95 %CI 1.2-4.6]) were independent predictors of response to POP. Clinical improvement after BTI is a predictor of response to POP in patients with gastroparesis. This information may aid in improving patient selection for POP.

S156] Comparing outcomes of per-oral pyloromyotomy and robotic pyloroplasty for the treatment of gastroparesis.

Gastroparesis is characterized by delayed gastric emptying without a significant obstructive pathology and is estimated to effect more than 5 million adults in the United States. Therapies for this condition are divided into two categories: gastric electrical stimulation or pyloric therapies to facilitate gastric emptying. Pyloric procedures include pyloroplasty, a well-documented procedure, and per-oral endoscopic myotomy (POP), a relatively novel endoscopic procedure that disrupts the pyloric muscles endoscopically. There is a paucity of literature comparing the two procedures. The aim of this study is to compare the outcomes of these two techniques. Under an IRB protocol, data were collected prospectively from September 2018 through April 2021 at our institution for patients undergoing POP (n = 63 patients) or robotic pyloroplasty (RP) (n = 48). Preoperative and postoperative data including sex, race, age, BMI, and Gastroparesis Cardinal Symptom Index (GCSI) score were analyzed using univariate and multivariate analysis. There was no significant difference in sex, age, and BMI for both cohorts, but patients with RP were more likely to have private insurance, pre-op reflux, and PPI (p < .05 for all). Patients who underwent POP had significantly shorter operative time compared to RP (median 27min vs 90, p < 0.001). The average change between preoperative and postoperative GCSI scores was significantly decreased for both interventions (POP mean = 8.2, RP 16.8, p < 0.001 both). However, comparing both data, RP has significantly better improvement in postoperative GCSI score than POP in both univariate (p < 0.001) and multivariate analysis (p = 0.030). This was reflected in the individual symptoms with nausea (p < 0.001), ability to finish meal (p = 0.037), abdomen visibly larger (p = 0.037) and bloating (p = 0.022) all showing improvement in both groups, but with RP having a more significant decrease in the scoring of these symptoms than POP. There was no significant difference in the number of postoperative complications (POP 19% vs RP 13%, p = 0.440). Even though both interventions are significantly associated with improvement of symptoms in patients with gastroparesis, our data demonstrates that robotic pyloroplasty has a superior response in comparison to per-oral endoscopic myotomy for the management of these symptoms. Per-oral pyloromyotomy has a similar complication rate to robotic pyloroplasty with a shorter operative time.

Safety and feasibility of same day discharge after per oral endoscopic pyloromyotomy in refractory gastroparesis: a pilot study.

Background:Gastroparesis is a debilitating medical condition with limited treatment options. Gastric per-oral pyloromyotomy (G-POEM) has emerged as a promising treatment option with remarkable short-term clinical success shown in multiple studies. While the post-procedure protocol is not standardized across many centers, the majority of the centers observes these patients in the hospital after the procedure for monitoring. In this single-center prospective study, we evaluated the safety and feasibility of same day discharge after the G-POEM procedure.Methods:All the patients with refractory gastroparesis undergoing G-POEM from October 2019 to March 2020 were enrolled. A total of 25 patients were enrolled in the procedure. Based on the pre-defined criteria, patients were either discharged on the same day after the procedure or admitted to the hospital for further observation. The patient and procedure-related data were extracted from the chart review. Univariate analysis was performed (chi-squared test) on categorical variables after organizing categorical variables as numeric counts or percentages. The student t test was performed on continuous variables after reporting as mean and standard deviation. For analysis with a smaller sample size, Fisher exact and Mann–Whitney tests were used.Results:A total of 25 patients were enrolled. The technical success of G-POEM was 100% and clinical success was 80% (20/25) at 1-month follow-up. Of the 25 patients, 9 patients (36%) were discharged on the same day according to the procedure from the recovery unit. Of the remaining 16 patients who were admitted to the hospital post-procedure, 10 (40%) were admitted due to procedure-related causes while other admissions were either pre-planned or due to social reasons. The average Charlson comorbidity index was lower in the same day discharge group (P < 0.05). The number of patients requiring double myotomy was higher in the same day discharge group (P < 0.05). The overall complication rate of G-POEM in the study cohort was 12% (3/25) with all complications being mild without any severe adverse events.Conclusion:G-POEM is a safe and effective method of treatment for refractory GP with higher clinical success in short-term follow-up. The same day discharge after G-POEM is safe and feasible in >50% of patients with close periprocedural monitoring.

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.

Gastroparesis with concomitant gastrointestinal dysmotility is not a contraindication for per-oral pyloromyotomy (POP).

Per-oral pyloromyotomy (POP or G-POEM) provides significant short-term improvements in symptoms and objective emptying for patients with medically refractory gastroparesis, but it is unclear if patients with gastroparesis and co-existing dysmotility (small bowel or colonic delay) also benefit. In this study, we used wireless motility capsule (WMC) data to measure outcomes in patients with isolated gastroparesis (GP) and gastroparesis with co-existing dysmotility (GP + Dys) who underwent POP. We retrospectively analyzed patients who had POP and completed WMC data during their evaluation of intestinal dysmotility. WMC data were reviewed to identify patients who demonstrated isolated GP or GP + Dys. Each patient's pre-op and post-op Gastroparesis Cardinal Symptom Index (GCSI) and 4-h solid-phase scintigraphy gastric emptying studies (GES) scores were compared to evaluate improvement. Of the entire cohort (n = 73), 89% were female with a mean age of 47.0 ± 15.0years old. Gastroparesis etiologies were divided among idiopathic (54.8%), diabetic (26%), postsurgical (8.2%), autoimmune (5.5%), and multifactorial (5.5%).Forty-one patients (56%) had GP and 32 patients (44%) had GP + Dys. GCSI improved after POP whether the patient had isolated GP (- 12.31, p < 0.001) or GP + Dys (- 9.58, p < 0.001); however, there was no significant difference in total GCSI improvement between the two groups. A subset of patients had postoperative GES available (n = 47). In the isolated GP and GP + Dys cohorts, 15/28 (54%) and 12/19 (63%) patients had normal post-op 4-h GES, respectively, but no statistical difference between the two groups. Patients with medically refractory gastroparesis with and without concomitant gastrointestinal dysmotility show short-term subjective and objective improvement after POP. Concomitant small bowel or colonic dysmotility should not deter physicians from offering POP in carefully selected patients with gastroparesis.

Beyond Metoclopramide for Gastroparesis

Beyond Metoclopramide for Gastroparesis

Short-term outcomes of different modalities of pyloromyotomy versus gastric electrical stimulation in the treatment of gastroparesis: A systemic review and meta-analysis.

Background:The aim of this meta-analysis was to compare the short-term outcomes surrounding the efficacy and complication rate between different modalities of pyloromyotomy and gastric electrical stimulation (GES) in the treatment of gastroparesis.Methods:Comprehensive, computerized research was performed on PubMed, Embase, and the Cochrane Central Register of Controlled Trials. We additionally reviewed relevant articles, without any language limitations, published prior to April 15, 2020. Meta-analysis was conducted using RevMan 5.3 software.Results:Three studies totaling 196 participants who had received 4 interventions, including single per-oral pyloromyotomy (POP), double POP, laparoscopic pyloromyotomy, and GES, were eligible for analysis. Compared to single POP, double POP achieved a better clinical response with a pooled relative risk (RR) of 1.27 (95% confidence interval [CI], 1.01–1.60, P = .04), while laparoscopic pyloromyotomy and GES showed no difference with a pooled RR of 0.89 (95% CI, 0.74–1.08, P = .23) and 0.87 (95% CI, 0.73–1.04, P = .13), respectively. As for the recurrence and complication rates, only GES showed a borderline significance of recurrence in comparison to single POP (RR 2.17, 95% CI, 1.00–4.71, P = .05), while there were no differences in the remainder of the comparisons.Conclusions:We conducted a detailed comparison of 3 modalities of pyloromyotomy and GES in the treatment of gastroparesis, with the results suggesting that double POP demonstrated better clinical success with similar recurrence and complication rates. In addition, GES may result in more recurrence amongst these interventions.

Pyloric distensibility in health and disease.

Until recently, gastric motility measurements in humans were mostly limited to accommodation (using barostat or 3-dimensional imaging studies of gastric volume) and gastric emptying tests, the latter being the only one performed in routine clinical care. Accurate and easy to use techniques were lacking to assess pyloric function in health and disease. Recently, pyloric distensibility has been developed and validated to assess pyloric opening. Several studies confirmed that pyloric distensibility was decreased in gastroparesis and correlated with gastric emptying as well as gastroparesis symptoms. In addition, pyloric distensibility may predict outcome of endoscopic techniques targeting the pylorus, namely intrapyloric botulinum toxin injection and gastric per-oral pyloromyotomy. Pyloric distensibility appears therefore to be a promising and useful new tool in the workup of gastroparesis patients.

Significant changes in impedance planimetry (EndoFLIP™) measurements after peroral pyloromyotomy for delayed gastric emptying.

The endoluminal functional lumen imaging probe (FLIP) can be used to obtain real-time measurements of the diameter (Dmin), cross-sectional area (CSA), and distensibility of the pylorus before and after peroral pyloromyotomy (POP), an emerging endoscopic treatment for delayed gastric emptying. Our study aims to report our single-center experience in performing POP with FLIP measurements before and after pyloromyotomy. A retrospective review of a prospectively maintained gastroesophageal database was performed. Demographic and perioperative data, including intraoperative FLIP measurements of the pylorus before and after POP, were analyzed. Measurements were compared using paired t tests. Thirty-four patients underwent POP between February 2017 and July 2020. Twenty-three (67.7%) patients were male and the average age was 59years. The etiology of delayed gastric emptying was post-vagotomy in 22 patients, idiopathic gastroparesis in 7 patients, and diabetic gastroparesis in 5 patients. There were no significant differences in pre-myotomy or post-myotomy FLIP measurements when comparing the post-vagotomy versus the gastroparesis groups. There were significant increases in Dmin, CSA, and distensibility index when comparing pre-myotomy and post-myotomy readings for all patients (all p < 0.001). At follow-up, 64.7% of patients reported resolution of all symptoms. POP is an effective intervention in patients with delayed gastric emptying. Significant changes in FLIP measurements before and after POP suggest that FLIP may be a useful adjunct in guiding the management of delayed gastric emptying.

Gastrectomy for gastroparesis: when and how

: Gastroparesis is a chronic and debilitating gastric motility disorder characterized by delayed gastric emptying in the absence of mechanical obstruction. The disease is frequently refractory to medical therapies, and multiple surgical options exist to treat medically refractory gastroparesis. However, a formal management algorithm has yet to be agreed upon. Furthermore, the best utilization and approach for the most extreme surgical option, gastrectomy, continues to be debated. This review article presents our surgical treatment algorithm and provides an overview of the literature surrounding various surgical options currently used in practice including gastric electrical stimulation, pyloroplasty, per-oral pyloromyotomy (POP), enteral feeding tubes, and sleeve gastrectomy. We additionally take a deeper look at the end of the line surgical therapy, gastrectomy, in an attempt to answer the question of when and how this definitive surgery should be utilized. While a gastrectomy is an extreme surgical treatment modality, for patients who fail less invasive surgical measures, gastrectomy often has favorable results in controlling symptoms and improving patients’ quality of life with an acceptable morbidity rate. However, gastrectomy should only be considered after exhausting all organ-sparing options. While there is no “one size fits all” surgical treatment modality for refractory gastroparesis, our recommendation for a definitive operation for medically refractory gastroparesis is a laparoscopic or robotic subtotal gastrectomy with a Roux-en-Y gastrojejunostomy reconstruction.

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.

S1320 Does a Response to Botulinum Toxin Injection Predict a Future Response to Per Oral Pyloromyotomy (POP) in Patients With Gastroparesis?

INTRODUCTION: Gastroparesis is a chronic gastrointestinal condition characterized by varying degrees of symptoms. It is often difficult to treat with limited viable options. Recently, a new technique called peroral endoscopic pyloromyotomy (POP) was developed which involves cutting the pyloric muscle by creating a submucosal tunnel. It has been thought that responsiveness to pyloric botulinum toxin (BT) injection may predict a response to POP. Our hypothesis is that a clinical response to BT injection of the pyloric sphincter is not a predictor of a clinical response to POP. METHODS: A retrospective study was performed at Cleveland Clinic from January 2016 to September 2019. Data from all patients who underwent POP was collected. We included patients who underwent BT injection prior to undergoing POP. We excluded all patients who did not undergo BT injection. Data such as age, sex, use of opioids and prokinetics at the time the POP is performed, etiology and prior interventions to treat gastroparesis including presence of gastric pacemaker and BT response was collected. All data analyses were conducted using SAS version 9.4. RESULTS: A total of 471 patients underwent POP at our institutions over the study period out of which 125 subjects were included in the analysis. Patients had a median age of 42.0 years, and 83.2% were females. The predominant etiology was idiopathic (59.2%) followed by diabetes (20.8%). Overall, 78 patients had improvement with BT, 82 had improvement with POP and 56 with both. On regression analysis, a response to BT did not predict improvement with POP (P = 0.18) and there was no difference seen with age, gender, etiology, prokinetic use, opioid use or presence of a pacemaker. CONCLUSION: POP may be a viable procedure for medically refractory gastroparesis in eligible patients. However, in this cohort of patients, a positive response to pyloric BT injection did not correspond to a positive response to POP. A positive response to POP was not predicted by any factors collected.Figure 1.: Patient Inclusion.Table 1.: Results of the logistic regression for main analysis demonstrating the odds ratio (OR) and 95% Confidence Intervals (CI) for covariates. The OR represents likelihood of improvement following POP

Significant Changes in Impedance Planimetry (EndoFLIP) Measurements after Peroral Pyloromyotomy (POP) for Delayed Gastric Emptying

Attaar, Mikhail MD; Su, Bailey MD; Wong, Harry MD; Kuchta, Kristine MS; Stearns, Stephen BS; Ujiki, Michael MD, FACS Author Information

S0936 Psychiatric Comorbidities and Multidisciplinary Management of Patients Undergoing Gastric Per-Oral Endoscopy Pyloromyotomy (GPOEM) for Refractory Gastroparesis: Preliminary Outcomes

S0936 Psychiatric Comorbidities and Multidisciplinary Management of Patients Undergoing Gastric Per-Oral Endoscopy Pyloromyotomy (GPOEM) for Refractory Gastroparesis: Preliminary Outcomes

Endoscopic Per-oral Pyloromyotomy for Gastroparesis: Initial Experience and Postoperative Comparison to Predicted Complications Following Laparoscopic Pyloromyotomy as Calculated by the ACS Risk Calculator

Per-oral endoscopic pyloromyotomy (POP) is a promising new therapy in the treatment of gastroparesis, where the pyloric muscle is cut using an endoscopic tunneling technique. This study was designed to report outcomes from our initial experience and compare the rate of complications to the laparoscopic equivalent using the American College of Surgeons (ACS) risk calculator. Patients who underwent POP between August 2018 to May 2019 were prospectively followed in a database approved by the institutional review board. Preoperatively, patients were evaluated objectively with a 4-hour gastric emptying study (GES). Following POP, all patients were invited for repeat GES 3 months postoperatively. The same cohort was entered into the ACS risk calculator using laparoscopic pyloromyotomy (LPM) as the selected procedure. Complication risk of LPM was then compared with the actual complication rate of POP. There were 11 patients that met study criteria (median age 52). Sixty-four percent (7/11) of patients agreed to do repeat GES postoperatively. Of those, 6 of 7 (86%) had normal GES (<10% emptying at 4 h) and the mean improvement was 36.4%. All patients were entered into the ACS risk calculator in which LPM (CPT code 43800) was used as a control. The postoperative complication rate was less than the median predicted risk of LPM in all categories including overall complications (0% vs. 10.05%), return to the operating room, (0% vs. 2.68%), and sepsis (0% vs. 1.42%). The rate of readmission (9% vs. 6.29%, P=0.65) was higher in the POP group than LPM predicted. Length of stay for all patients was significantly shorter than predicted (1.8 vs. 4.6 d, P<0.001). All POP patients had objective improvement in their GES and 86% had normal GES following this procedure. POP had significantly lower morbidity and reduced length of stay compared with that predicted of the laparoscopic equivalent using the ACS risk calculator.

Bariatric endoscopy: current primary therapies and endoscopic management of complications and other related conditions

The steady increase in bariatric surgery has led to room for innovation. Endoscopy has become an important tool for evaluation, diagnosis, management of complications, and even for primary bariatric interventions. Leaks are the most feared complication and new endoscopic therapies have been developed such as septotomy, double-pigtail stents, and endoscopic vacuum therapy. Additionally, primary bariatric endoscopic procedures are gaining popularity and the new procedures include intragastric balloons, stoma reduction, aspiration therapy, among others. The altered anatomy and reoperation increase the risk of complications after bariatric surgery, especially when managing conditions like achalasia, gastroparesis, and cholelithiasis. Per-oral endoscopic myotomy, per-oral pyloromyotomy, and endoscopic ultrasound-guided transgastric endoscopic retrograde cholangiopancreatography provide a less invasive approach to address these conditions. This narrative review article intends to expose current endoscopic therapies for the management of primary bariatric procedures, complications and related conditions.