Gastric peroral endoscopic myotomy for refractory gastroparesis.

Gastric peroral endoscopic myotomy (G-POEM) was first described by Khashab et al1Khashab M.A. Stein E. Clarke J.O. et al.Gastric peroral endoscopic myotomy for refractory gastroparesis: first human endoscopic pyloromyotomy (with video).Gastrointest Endosc. 2013; 78: 764-768Abstract Full Text Full Text PDF PubMed Scopus (174) Google Scholar in 2013. The idea of G-POEM is to relieve pyloric spasm, a major factor in the pathogenesis of gastroparesis.2Liu N. Abell T. Gastroparesis updates on pathogenesis and management.Gut Liver. 2017; 11: 579-589Crossref PubMed Scopus (51) Google Scholar G-POEM is a logical expansion of third-space endoscopy in which tunneling is used to cut the pyloric muscle, keeping an intact mucosa above. The technical success of G-POEM is nearly 100%; however, clinical success usually ranges from 74% to 87%.3Aghaie Meybodi M. Qumseya B.J. Shakoor D. et al.Efficacy and feasibility of G-POEM in management of patients with refractory gastroparesis: a systematic review and meta-analysis.Endosc Int Open. 2019; 7: E322-E329Crossref PubMed Google Scholar Postsurgical gastroparesis has the most favorable outcomes.4Xu J. Chen T. Elkholy S. et al.Gastric peroral endoscopic myotomy (G-POEM) as a treatment for refractory gastroparesis: long-term outcomes.Can J Gastroenterol Hepatol. 2018; 2018: 6409698Crossref PubMed Scopus (34) Google Scholar The gastroparesis cardinal symptom index (GCSI) is a clinical scoring system used to assess the clinical severity of gastroparesis.5Dacha S. Mekaroonkamol P. Li L. et al.Outcomes and quality-of-life assessment after gastric per-oral endoscopic pyloromyotomy (with video).Gastrointest Endosc. 2017; 86: 282-289Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar Gastric emptying scintigraphy (GES) is also used to measure the half emptying time and percentage of residual food after 4 hours. GCSI and GES are used not only for the diagnosis of gastroparesis but also for predicting response.4Xu J. Chen T. Elkholy S. et al.Gastric peroral endoscopic myotomy (G-POEM) as a treatment for refractory gastroparesis: long-term outcomes.Can J Gastroenterol Hepatol. 2018; 2018: 6409698Crossref PubMed Scopus (34) Google Scholar Here, we present a 42-year-old man with a history of refractory reflux disease, for which fundoplication was done 2 years earlier. Two months after the operation, the patient started to develop nausea, fullness, and bloating. Prokinetics were prescribed but yielded limited response. The patient’s condition progressed, and he started to develop frequent attacks of vomiting, early satiety, and loss of weight. His GCSI was 25, mean GES was 139.8 minutes (normal: up to 120 minutes), and retention percentage at 2 hours was 65.9% (normal: up to 60%). After discussing the treatment options with the patient, G-POEM was chosen. The patient signed informed consent before the procedure. He was placed in a supine position and was under general anesthesia with endotracheal intubation. Prophylactic antibiotics were given in the form of third-generation cephalosporins and metronidazole. A high-definition therapeutic gastroscope was used with an auxiliary water channel (GIF-1TH 190; Olympus, Tokyo, Japan). A transparent cap (D-201-11802; Olympus) was fitted to the end of the endoscope to provide better visualization of the submucosa and to help in dissection. Carbon dioxide insufflation was used throughout the entire procedure. Endo Cut Q (effect 3, duration 3) and forced coagulation (50 W, effect 2) were the electrosurgical settings used (VIO-300D; Erbe, Tubingen, Germany). The solution used for injection was sterile 0.9% saline solution mixed with 1% methylene blue. Hybrid knife (T-type Erbe) was used. Hybrid knives help in cutting coagulation and injection. Coagulation forceps (FD-410 LR; Olympus) was used when large blood vessels or bleeding that could not be stopped with knife coagulation were encountered. An insulated-tip knife nano type (IT, KD-612L/U; Olympus) was used for myotomy. As shown in the video (Video 1, available online at www.VideoGIE.org), a submucosal bleb was made 5 cm proximal to the spastic pylorus (Fig. 1). Opening of the tunnel was performed (Fig. 2), followed by submucosal dissection (Fig. 3) until reaching the pyloric ring (half-moon sign) (Fig. 4), followed by cutting of the pyloric ring using an IT knife with proximal extension of the myotomy (Fig. 5). Caution should be taken to avoid mucosal injury to prevent complete perforation. The tunnel opening was closed with hemoclips (Fig. 6). The pyloric ring was widely opened (Fig. 7). Detailed steps of G-POEM are shown in Figure 8. After 6 months of follow-up, the patient’s condition markedly improved (GSCI = 3), and he started to gain weight.Figure 2Opening of the tunnel.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3Dissection in the tunnel.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 4Pyloric ring appearing as a half-moon after dissection.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 5Cutting the pyloric ring using insulated tip knife.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 6Final closure with clips.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 7Pyloric ring widely opened.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 8Steps of gastric peroral endoscopic myotomy.View Large Image Figure ViewerDownload Hi-res image Download (PPT) All authors disclose no financial relationships. https://www.videogie.org/cms/asset/18d06491-1b5b-424b-bba2-c49102d8b811/mmc1.mp4Loading ... Download .mp4 (122.31 MB) Help with .mp4 files Video 1Video demonstrating the steps of gastric peroral endoscopic myotomy (G-POEM). Fundoplication is noted on retroversion of the endoscope. Spastic pyloric ring is also noted. A submucosal bleb 5 cm proximal to the pyloric ring is formed, followed by opening of the tunnel and dissection in the tunnel until reaching the pyloric ring. The pyloric ring is cut with the IT knife. Widening of the pylorus is noted. Closure of the tunnel opening with hemoclips. Comparison of the pylorus before and after G-POEM showed marked opening of the pyloric ring.