Gastric per-oral endoscopic myotomy: Indications, technique, results and comparison with surgical approach

Abstract

Gastroparesis is a chronic disease of the stomach that causes a delayed gastric emptying, without the presence of a stenosis. For 30 years the authors identified pylorospasm as one of the most important pathophysiological mechanisms determining gastroparesis. Studies with EndoFLIP, a device that assesses pyloric distensibility, increased the knowledge about pylorospasm. Based on this data, several pyloric-targeted therapies were developed to treat refractory gastroparesis: Surgical pyloroplasty and endoscopic approach, such as pyloric injection of botulinum and pyloric stenting. Notwithstanding, the success of most of these techniques is still not complete. In 2013, the first human gastric per-oral endoscopic myotomy (GPOEM) was performed. It was inspired by the POEM technique, with a similar dissection method, that allows pyloromyotomy. Therapeutical results of GPOEM are similar to surgical approach in term of clinical success, adverse events and post-surgical pain. In the last 8 years GPOEM has gained the attention of the scientific community, as a minimally invasive technique with high rate of clinical success, quickly prevailing as a promising therapy for gastroparesis. Not surprisingly, in referral centers, its technical success rate is 100%. One of the main goals of recent studies is to identify those patients that will respond better to the therapies targeted on pylorus and to choose the better approach for each patient.

Endoscopic Management of Post-Sleeve Gastrectomy Complications

“…Gastric per-oral endoscopic myotomy (G-POEM), first described in 2013 by Khashab et al, is an endoscopic technique which involves submucosal tunneling to incise distal antral and pyloric musculature in gastroparesis [95]. While G-POEM is effective in the treatment of medically refractory gastroparesis, it has also been explored as a treatment option in patients with GSS [96][97][98]. In a study of 13 patients with GSS, G-POEM had a clinical success rate of 77%, and no major complications were reported [99].…”

Targeting the pylorus in gastroparesis: From physiology to endoscopic pyloromyotomy

“…A control by a second upper endoscopy on Day 1 can be considered to exclude a leak and to confirm the effectiveness of the incision closure with the clips being still present. Some centers use a contrast study after the procedure 76 . In the absence of complications, the patient might restart feeding progressively (liquid on the first day and then a soft diet) and could be discharged on day 1.…”

“…Some centers use a contrast study after the procedure. 76 In the absence of complications, the patient might restart feeding progressively (liquid on the first day and then a soft diet) and could be discharged on day 1. Proton pump inhibitors should be given to the patient during the procedure and for 4 weeks after the procedure twice a day.…”

Third-space endoscopy: the final frontier

“…Hence, withdrawing the endoscope into the lumen and reinsertion into the submucosal tunnel is usually performed several times so as to ensure progression in the right direction towards the pylorus muscle. Once the pylorus is identified, a 2- to 3.5-cm myotomy is performed [ 57 ]. Technical variations on the myotomy (partial vs full-thickness, “single vs double” myotomy, width of the myotomy) have been proposed yet high-quality data are lacking [ 40 , 58 , 59 ].…”