Outcomes of per oral endoscopic pyloromyotomy in gastroparesis worldwide

Per oral endoscopic pyloromyotomy(POP),also known as gastric per-oral endoscopic myotomy(GPOEM),is a novel procedure with promising potential for the treatment of gastroparesis.As more data emerge and the procedure is becoming more recognized in clinical practice,its safety and efficacy need to be carefully evaluated.Appropriate patient selection for favorable clinical success prediction after GPOEM also needs additional research.This review aims to systemically summarize the existing data on clinical outcomes of POP.Symptomatologic responses to the procedure,its adverse effects,procedural techniques,and predictive factors of clinical success are also discussed.

Double Incomplete Pyloromyotomy (A. Ezzat Technique): A New Technique for Infantile Hypertrophic Pyloric Stenosis: Preliminary Study

Background-Purpose: The study aimed to see the outcome of Double Incomplete Pyloromyotomy as new technique for surgical management of infantile hypertrophic pyloric stenosis (IHPS). Methods: This study was conducted in pediatric surgery unite, Zagazig University Hospital, Egypt. Fifteen patients were included in this study (11 male and 4 female) with IHPS from January 2012 to January 2013. Under general anesthesia, two longitudinal separated incisions at different planes as pyloromyotomy. Results: Postoperative vomiting and weight gain were recorded. Follow up period was 3 months. Vomiting improved within first 48 hours then stopped after that. Weight gain significantly increased after theoperation when compared preoperatively. Conclusion: Double Incomplete Pyloromyotomy is a new, safe and effective procedure for treatment of infantile hypertrophic pyloric stenosis.

Do Immaturity, Dehydratation or Alkalosis Predispose to Intraoperative Complications at Pyloromyotomy?

Background: Hypertrophic pyloric stenosis is the most important cause for propulsive non-bilious vomiting in infants of the first trimester. Extramucous splitting of the hypertrophic pyloric muscle is the surgical gold standard for treatment. Serious major complications of pyloromyotomy (PM) are mucosal perforation and incomplete muscle splitting. The aim of the presented study is to find out if intraoperative complications are predisposed by biometric or biochemical factors. Furthermore, we looked for the influence of the board certification of the primary surgeon. Patients and Methods: 162 infants with IHPS were operated during a six-year period (n = 150 laparoscopic operations). We had 8 major complications (4.9%): iatrogenic mucosal perforation occurred in 6 cases, and incomplete PM in 2 infants. Preoperative demographic data and data resulting from the blood acid-base- and ion-analysis were compared with data of a previously published reference group from our institution (Tr?bs RB. Open J Pediatr, 2014;4: 208-215). Results: The duration of vomiting, the grade of dehydration and the severity of blood alkalosis did not differ between both groups. Furthermore, we found no influence of the gestational age and birth weight on the occurrence of intraoperative complications. It seems that early postnatal age (p = 0.07) and low body weight at surgery (p = 0.055) may contribute to surgical problems. Board certification as a paediatric surgeon did not influence the rate of intraoperative complications. Conclusions: Laboratory data did not show any predisposition to intraoperative complications. It is assumed that small infants with early occurring symptoms carry an elevated risk for intraoperative events. Our data support the hypothesis that the rate of intraoperative complications at PM is mainly influenced by skills and experience of the surgeon.

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.

Fluoroscopic gastric peroral endoscopic pyloromyotomy(G-POEM)in patients with a failed gastric electrical stimulator

Background:Gastric electrical stimulators(GESs)have been used to treat refractory gastroparesis in patients who fail initial therapies such as dietary modifications,control of psychological stressors and pharmacologic treatment.More recently,gastric peroral endoscopic pyloromyotomy(G-POEM)has emerged as a novel endoscopic technique to treat refractory gastroparesis.We present a case series of patients with refractory gastroparesis who failed treatment with an implanted GES that were safely treated with G-POEM performed under fluoroscopy as a salvage therapy.Methods:Cases of G-POEM performed on patients with refractory gastroparesis who failed treatment with a GES were retrospectively reviewed.All G-POEM procedures were performed under fluoroscopic guidance with the GES still in place.Gastroparesis Cardinal Symptoms Index(GCSI)and gastric emptying scintigraphy were assessed before and after the procedure.Patients were followed up for up to 18 months post procedure.Results:Five patients underwent G-POEM after failing treatment with a GES.Under fluoroscopy,the GES and their leads were visualized in different parts of the stomach.One GES lead was observed at the antrum near the myotomy site.All procedures were successfully completed without complications.Patients’GCSI decreased by an average of 62%1 month post procedure.Patients also had notable improvements in gastric emptying 2 months post procedure.Conclusion:In patients with refractory gastroparesis who have failed treatment with a GES,G-POEM can be safe and effective without removing the GES.To visualize the GES and avoid cutting GES leads during myotomy,the procedure should be performed under fluoroscopy.

Gastric per-oral endoscopic myotomy: Current status and future directions

Gastroparesis, or symptomatic delayed gastric emptying in the absence of mechanical obstruction, is a challenging and increasingly identified syndrome. Medical options are limited and the only medication approved by the Food and Drug Administration for treatment of gastroparesis is metoclopramide, although other agents are frequently used off label. With this caveat, first-line treatments for gastroparesis include dietary modifications, antiemetics and promotility agents, although these therapies are limited by suboptimal efficacy and significant medication side effects. Treatment of patients that fail first-line treatments represents a significant therapeutic challenge. Recent advances in endoscopic techniques have led to the development of a promising novel endoscopic therapy for gastroparesis via endoscopic pyloromyotomy, also referred to as gastric per-oral endoscopic myotomy or per-oral endoscopic pyloromyotomy. The aim of this article is to review the technical aspects of the per-oral endoscopic myotomy procedure for the treatment of gastroparesis, provide an overview of the currently published literature, and outline potential next directions for the field.

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

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 treatment of gastroparesis

Gastroparesis has traditionally been a largely medically managed disease with refractory symptoms typically falling under the umbrella of the surgical domain.Surgical options include, but are not limited to, gastrostomy,jejunostomy, pyloromyotomy, or pyloroplasty,and the Food and Drug Administration approvedgastric electrical stimulation implantation. Endoscopic management of gastroparesis most commonly involves intrapyloric botulinum toxin injection; however, there exists a variety of endoscopic approaches on the horizon that have the potential to radically shift standard of care.Endoscopic management of gastroparesis seeks to treat delayed gastric emptying with a less invasive approach compared to the surgical approach. This review will serve to highlight such innovative and potentially transformative, endoscopic interventions available to gastroenterologists in the management of gastroparesis.

Recent advances in third space or intramural endoscopy

Third space endoscopy or intramural endoscopy is based on the principle that the deeper layers of the gastrointestinal tract can be accessed by tunneling in the submucosal space and maintaining the integrity of the overlying mucosa.The era of third space endoscopy started with peroral endoscopic myotomy(POEM)for treatment of achalasia and has expanded to treat various other gastrointestinal disorders.The technique is also currently used for treatment of refractory gastroparesis,Zenker’s diverticulum(ZD),resection of subepithelial tumors and early cancers of the gastrointestinal tract and Hirschsprung’s disease(HD).These procedures are rapidly emerging as minimally invasive alternatives to conventional surgery.They are safe and effective with excellent outcomes.This review focuses on the evolution and current applications of third space endoscopy in various gastrointestinal disorders.Key points:(1)Third space or intramural endoscopy initially started with the POEM procedure for treatment of achalasia;(2)Advancements in procedural techniques have expanded its application to treat other gastrointestinal disorders such as refractory gastroparesis,ZD,HD,resection of subepithelial tumors and early gastrointestinal cancers;(3)These procedures are highly effective with excellent outcomes and low complication rates;and(4)Third space endoscopic procedures are rapidly emerging as minimally invasive alternatives to conventional surgery.

New insights on the pathogenesis of pyloric stenosis of infancy. A review with emphasis on the hyperacidity theory

A review is presented on the theories concerning the cause of pyloric stenosis with emphasis on the primary position of inherited hyperacidity in pathogenesis. Existing theories are critically analysed and the hyperacidity theory is precisely defined in the light of recent physiological insights into the gastrointestinal hormone motilin. The progressive fixed fasting hypergastrinaemia within the first few weeks of life will, in the baby who inherits acid secretion at the top of the normal range, produce hyperacidity of sufficient severity to trigger the process of acid-induced work hypertrophy of the pylorus. The potential contribution of motilin is discussed. The baby who inherits a normal gastric acidity will not reach acid levels severe enough to trigger sphincter hypertrophy despite the early gastrin stimulus. The potential threat will cease when gastrin naturally declines with age and the pyloric canal becomes wider. Genetic factors clearly must also be involved and these are separately discussed.