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

  • Mark J. AndersonEmail author
  • Megan Sippey
  • Jeffrey Marks
Multimedia Article
  • 20 Downloads

Abstract

Background

Following 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 Methods

The 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.

Results

We 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.

Conclusions

GPOP 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.

Keywords

gastroparesis esophagectomy endoscopic pyloromyotomy per-oral pyloromyotomy POP POEM 

Notes

Compliance with Ethical Standards

Conflict of Interest

Drs. Anderson and Sippey have no conflicts of interests or financial ties to disclose. Dr. Jeffrey M. Marks has received consultant fees from Boston Scientific and Olympus with no direct relation to this study

Supplementary material

11605_2019_4418_MOESM1_ESM.mov (255.4 mb)
Video 1 Per-oral pyloromyotomy for post-esophagectomy gastroparesis (MOV 255 mb)

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Copyright information

© The Society for Surgery of the Alimentary Tract 2019

Authors and Affiliations

  1. 1.Department of Surgery, Case Western Reserve University School of MedicineUniversity Hospitals Cleveland Medical CenterClevelandUSA

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