Peroral Pyloromyotomy Research Articles

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.

Gastric Per Oral Pyloromyotomy for Post-Vagotomy-Induced Gastroparesis Following Esophagectomy

BackgroundFollowing the success of per-oral endoscopic myotomy (POEM) for achalasia, application of this minimally invasive skillset has broadened to other disease processes. Since 2013, gastric per-oral pyloromyotomy (GPOP) has become an increasingly accepted therapy for refractory gastroparesis. Although it does not treat the underlying etiology of the disease, pyloromyotomy has demonstrated measurable improvements in gastric emptying scintigraphy, nausea, and quality of life. Gastroparesis is a common complication of esophagectomy due to the inherent vagotomy that occurs during creation of the gastric conduit. Fifteen to 30% of post-esophagectomy patients develop gastroparesis with a large portion of them reporting symptoms refractory to medical therapy, botox injection, and endoscopic dilation. Therefore, GPOP may have the potential to offer symptomatic relief to a significant population of debilitated post-esophagectomy patients. Materials and MethodsThe procedure was recorded using standard operating room equipment. Materials utilized included high-definition single-channel gastroscope, therapeutic overtube, clear endoscopic cap, triangle tip (TT) knife, ERBE energy source, endoscopic clips, sclerotherapy needle, methylene blue with epinephrine, and CO2 insufflator. ResultsWe present a video of GPOP for a 71-year-old male with post-vagotomy-induced gastroparesis after esophagectomy. His pre-operative course was significant for persistent nausea and vomiting, diet intolerance, 20 lb weight loss, and frequent hospitalizations for aspiration pneumonia. Post-operatively, the patient recovered well and was discharged home on post-operative day 1 on a liquid diet. At 3-week follow-up, his nausea, vomiting, and PO intolerance had improved. At 6-month follow-up, he had no recent admissions for aspiration pneumonia and his pylorus remained widely patent on EGD. ConclusionsGPOP status post-esophagectomy presented multiple challenges: difficulty maintaining field of view and insufflation, establishing tension and counter tension for the mucosotomy, and a limited working space. With care and patience, endoscopists trained to perform POEM may apply their skillset to help a large population of patients suffering with post-esophagectomy gastroparesis.

Per-oral Pyloromyotomy for Treating Infantile Hypertrophic Pyloric Stenosis

Per-oral Pyloromyotomy for Treating Infantile Hypertrophic Pyloric Stenosis

Peroral pyloromyotomy for the treatment of infantile hypertrophic pyloric stenosis.

Peroral pyloromyotomy for the treatment of infantile hypertrophic pyloric stenosis.

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.

Endoscopic Peroral Pyloromyotomy Improves Glycemic Control in Gastroparesis Patients with Poorly Controlled Diabetes Mellitus

Endoscopic Peroral Pyloromyotomy Improves Glycemic Control in Gastroparesis Patients with Poorly Controlled Diabetes Mellitus

Long-term Results of Per-oral Pyloromyotomy for Refractory Gastroparesis

Long-term Results of Per-oral Pyloromyotomy for Refractory Gastroparesis

Per-Oral Pyloromyotomy (POP) for Medically Refractory Post-Surgical Gastroparesis

BackgroundPost-surgical gastroparesis (psGP) is putatively related to vagal denervation from either therapeutic transection or inadvertent injury. Here, we present a series of patients undergoing endoscopic per-oral pyloromyotomy (POP) as a treatment for medically refractory psGP. MethodsPatients identified from a prospectively maintained database of patients undergoing POP procedures at our institution from January 2016 to January 2018 were included. Surgical history, symptom scores, and gastric emptying studies before and 3 months after POP were additionally recorded. ResultsDuring the study period, 177 POP procedures were performed, of which 38 (21.5%) were for psGP. The study cohort was 84.2% female with a mean body mass index of 27.6 kg/m2 and mean age of 55.2 years. Common comorbidities included hypertension (34.2%), depression (31.6%), and gastroesophageal reflux disease (28.9%). Hiatal/paraesophageal hernia repair (39.5%) or fundoplication (36.8%) preceded psGP diagnosis most often. The mean operative time was 30 ± 20 min. There were no intraoperative complications. Mean postoperative length of stay was 1.2 days. There were two readmissions within 30 days, one for melena and one for dehydration. The mean improvement in total Gastroparesis Symptom Index Score was 1.29 (p = 0.0002). The mean 4-h gastric retention improved from a pre-POP mean of 46.4 to 17.9% post-POP. Normal gastric emptying was noted in 50% of subjects with available follow-up imaging. ConclusionPOP is a safe and effective endoscopic therapy for patients with psGP. POP should be considered a reasonable first-line option for patients with medically refractory psGP and may allow stomach preservation.

Endoscopic Intramural Surgery Part II: Muscular Division

AbstractThe development of endoscopic technologies and the introduction of new surgical concepts during the last decade has led to an evolution of surgical treatment of gastrointestinal disorders including achalasia, gastroesophageal reflux, gastroparesis, inflammatory bowel disease, and tumors of the gastrointestinal tract. Intramural surgery creates a novel approach to perform muscular division, submucosal dissection, and tumor removal. These procedures have proven safe and effective, and increasingly are part of the surgical endoscopist's toolbox. Intramural surgical procedures include peroral esophagomyotomy (POEM), peroral pyloromyotomy (POP), Zenker's diverticulotomy, and submucosal tunneling and endoscopic resection (STER) of lesions. The objective of this article is to describe current intramural surgery procedures that comprise muscular division, as well as clinical outcomes and its impact on surgical endoscopic practices.

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.

Factors Associated With Improvement of Symptom Index in Patients With Gastroparesis After Per-Oral Pyloromyotomy

Introduction: Gastroparesis is a debilitating disease and per oral pyloromyotomy (POP) is a fairly new endoscopic technique that has been proposed as an alternative to surgical pyloroplasty. Candidate selection for POP or patient factors associated with improved outcomes with POP need further evaluation. Given that the goal of this procedure is to improve patient symptoms and functioning, we have evaluated pre-operative patient factors associated with a significant improvement of Gastroparesis Cardinal Symptom Index (GCSI). Methods: We evaluated patients with gastroparesis who have both pre- and post-POP GCSI scores in the Cleveland Clinic health system. Baseline characteristics were described. Improvement was defined as post-operative minus pre-operative GCSI score of ≥ 5. Univariable logistic regression was used to evaluate demographic and clinical factors associated with improvement. Results: N=45 patients met inclusion criteria (98% female; mean age 45 years). Results of univariable logistic regression of factors associated with improvement in GCSI were outlined in Table 1. For every 1 point increase in the pre-POP GCSI, the odds of improved outcome increases by 12% [Odds Ratio (OR), 1.12 (95%CI: 1.01, 1.24)]. Specifically GCSI sub-scores of “bloating” [OR, 2.67 (95%CI: 1.39, 5.11)], and “stomach or belly is visibly larger” [OR, 2.96 (95%CI: 1.46, 6.02)] were both associated with improved outcomes (increment of 1 point). Percentage of patients with improved outcomes based on overall and sub-scores of GCSI were graphically represented (Figures 1a, 1b).442_A Figure 1. Univariate analysis of factors associated with significant improvement of GCSI score. Improvement is defined as difference between post-operative and pre-operative GCSI score of ≥ 5.Conclusion: In our analysis, high pre-operative GCSI score was the only factors associated with improved symptom outcomes after POP. Therefore, in evaluating a patient for POP, use of other expensive testing modalities may not be necessary. However, larger studies are needed to validate this conclusion.442_B Figure 2. Percent with improvement (defined as difference between post-operative and pre-operative GCSI score of ≥ 5) after per oral endoscopic pyloromyotomy as a function of preoperative GCSI score.442_C Figure 3. Percent with improvement after per oral endoscopic pyloromyotomy as a function of preoperative GCSI sub-score “Bloating” and “Stomach or belly is visibly larger”.

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

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

Per-oral Pyloromyotomy (POP) for Medically Refractory Gastroparesis

For patients with gastroparesis, temporary pyloric disruption has been shown to improve symptoms and gastric emptying. Per-oral pyloromyotomy (POP) is an innovative endoscopic procedure to divide the pylorus from within a submucosal tunnel, as a corollary to surgical pyloromyotomy. Here we evaluate subjective and objective outcomes 12-weeks after POP at a high volume center. The first 100 consecutive patients undergoing POP were included, with procedure dates between January 2016 and October 2017. Patients were evaluated using the Gastroparesis Cardinal Symptom Index (GCSI), and 4-hour solid-phase scintigraphic gastric emptying studies (GES) prior to procedure and at 90 days post-POP RESULTS:: The study cohort was 85% female with a mean age of 45.0 ± 14.6 years. Gastroparesis etiologies were divided among idiopathic (56%), diabetic (21%), postsurgical (19%), and other in 4%. There were 67% of the patients who had previous endoscopic or surgical interventions for gastroparesis. Most POP procedures were performed in the operating room (97%) and were completed in an average of 33 minutes. Ten patients incurred complications (10%), which included 1 diagnostic laparoscopy and 2 cases of gastrointestinal bleeding. Overall GCSI improved from a preoperative mean of 3.82 ± 0.86 to 2.54 ± 1.2 (P < 0.001). The improvement in each GCSI subscore was also highly statistically significant. Among the patients with postoperative GES available, 78% had objectively better 4-hour emptying with a mean improvement in retention by 23.6% (P < 0.001). This included 57% of patients with normal gastric emptying post-POP. For patients with medically refractory gastroparesis, POP results in both subjective and objective improvement in the majority of patients. Prior intervention does not obviate POP as a therapeutic option. POP should be included along the treatment algorithm for patients with gastroparesis as an organ-sparing procedure.

344 - Per-Oral Pyloromyotomy (POP) for Medically Refractory Post-Surgical Gastroparesis

Background Post-surgical gastroparesis (psGP) is putatively related to vagal denervation from either therapeutic transection or inadvertent injury. Here, we present a series of patients undergoing endoscopic per-oral pyloromyotomy (POP) as a treatment for medically refractory psGP.

How I Do It: Per-Oral Pyloromyotomy (POP)

IntroductionSeveral surgical treatments exist for treatment of gastroparesis, including gastric electrical stimulation, pyloroplasty, and gastrectomy. Division of the pylorus by means of endoscopy, Per-Oral Pyloromyotomy (POP), is a newer, endoluminal therapy that may offer a less invasive, interventional treatment option. MethodsWe describe and present a video of our step by step technique for POP using a lesser curvature approach. The following are technical steps to complete the POP procedure from the lesser curve approach. ConclusionIn our experience, these methods provide promising initial results with low operative risks, although long-term outcomes remain to be determined.

First Ever Per-Oral Pyloromyotomy in a Patient with Connective Tissue Disease

First Ever Per-Oral Pyloromyotomy in a Patient with Connective Tissue Disease

Endoscopic approaches to gastroparesis.

This review covers the cause, evaluation and treatment options for gastroparesis. Symptoms of delayed gastric emptying are increasingly seen by gastroenterologists and gastrointestinal surgeons. Endoscopy - both laparoscopic and flexible - is increasingly important in treatment algorithms for this problem. Gastroparesis is increasingly being seen in clinical practice. A progressive algorithm needs to be followed in these challenging cases: starting with medical treatment and diet modification, progressing through endoscopic treatments including new ones such as per-oral pyloromyotomy, and finally laparoscopic treatments including gastrectomy. Endoscopic interventions are effective treatments for certain gastroparesis patients. New procedures offer a minimally invasive alternative to more radical options and should probably be more widely adopted.

Early human experience with per-oral endoscopic pyloromyotomy (POP).

Gastroparesis is a condition characterized by delayed gastric emptying, and a constellation of symptoms, including nausea, vomiting, early satiety, and bloating. Although current surgical options such as pyloroplasty have been shown to be effective, an endoscopic submucosal myotomy technique may be applied to divide the pyloric sphincter without surgical access. Such endoscopic technique may provide the benefits of a natural orifice procedure, and improve gastric emptying in gastroparetic patients. Per-oral pyloromyotomy (POP) was performed in seven female patients aged 33-65 years (mean 51 years). All patients had a pre-operative work-up that included upper endoscopy, and a gastric emptying study. A pH study, and esophageal manometry were also performed when a concomitant fundoplication was considered. POP was technically successful in all seven cases. There were no immediate procedural complications. Perioperative, complications included: one patient with an upper GI bleed 2 weeks post-procedure, necessitating transfusions, and endoscopic clipping of a pyloric channel ulcer; one patient who experienced difficulty swallowing post operatively, delaying discharge by 1 day; and one patient who developed a hospital-acquired pneumonia, delaying discharge by several days. Six of the seven patients experienced significant symptomatic improvement following the procedure. Three month follow-up nuclear medicine solid-phase gastric emptying studies are currently available for 5 of the 7 patients. Normal gastric emptying at 4 h was noted in four of five patients (80 %). One patient did not respond to endoscopic management subsequently underwent an uneventful laparoscopic pyloroplasty, which also failed to significantly improve her symptoms. POP is a technically safe and feasible endoscopic procedure. Early follow-up suggests promising symptomatic improvement as well as objective improvement in gastric emptying. Additional clinical experience is required to establish the role of this technique in the management of gastroparesis.

360 Development of Novel Endoscopic Delivery Devices for Cell Sheets Transplantation

“Pop” the Pylorus! Per Oral Pyloro-Myotomya Novel Submucosal Endoscopy Technique Aman Ali*, Russell D. Yang Department of Medicine, Division of Gastroenterology, Southern Illinois University, Springfield, IL Introduction: Endoscopic submucosal dissection (ESD) and Per Oral Endoscopic Myotomy (POEM) procedures are elegant endoscopic techniques to explore the submucosal space and to offer minimally invasive approach to treat diseases that otherwise require invasive surgery. We envisioned using the submucosal space to access pylorus and to perform pyloro-myotomy. To our knowledge this has not been reported before. Potential applications of this technique could be in the endoscopic treatment of gastroparesis, pylorospasm, direct visualization injections to pylorus and other GI muscles and even in full thickness resection of gastric sub-epithelial neoplasms. Aim: To report feasibility of endoscopic per oral pyloro-myotomy in a live intubated porcine model. Methods. Study was approved by our animal lab facility. Two endoscopists with ESD experience performed the procedures. After adequate sedation, EGD (GIF 160, Olympus) was performed with a transparent cap attached. Pylorus was traversed a few times and ease of scope passage was rated on a scale of 1-5 (1 widely patenteasy passage; 5 spastic pylorus moderate resistance). After an adequate lift was obtained with a saline-methylene blue solution injection, a horizontal mucosal incision was made with Hybrid I knife (ERBE USA Inc., Marietta, GA), 10 cms proximal to the pylorus (Endocut Q, 30W,E2). Next the submucosal space was entered and tunneling was performed by submucosal dissection (dry cut -50W,E2), till pylorus was traversed and an open submucosal duodenal space was reached. Bleeding was controlled with soft coag (80W,E5). For myotomy, TT knife (Olympus Inc., Center Valley, PA) was used (spray coag 50W,E2) to hook & divide the inner transverse & oblique fibers, leaving intact the outer longitudinal fibers. Myotomy was started 5 cms proximal to pylorus and continued till pylorus was divided. Scope was withdrawn from submucosal tunnel and ease of scope passage was recorded again. Animals were euthanized and necropsy was performed. Procedure duration, mucosal injury, muscularis propria (MP) injury and perforation rates were recorded. Results: Between JulyNovember 2012, 5 POP procedures were performed. In the 1st two cases, athough ease of scope passage improved, necropsy revealed incomplete myotomy. Deeper incisions were performed in the remaining 3 procedures and necropsy confirmed the complete pyloro-myotomy. Mean duration of procedure was 63 minutes (range 53-75). No mucosal injury was seen. In one case intact serosa was seen but no perforations were noted. After POP the ease of scope passage improved from a mean score of 3.8 to 1.6. Non consequential MP injury was seen in 2/5 cases. Conclusion: Per Oral Pyloro-myotomy (POP) is a feasible procedure and we report first experience with this technique. Future animal lab data and survival models are required to further validate this technique.