Endoscopic Management: Interventions at the Pylorus

  • Andrew T. Strong
  • Matthew D. KrohEmail author


Gastroparesis is a functional disorder of the stomach defined by delayed gastric emptying, in the absence of mechanical obstruction. Classically subdivided into diabetes associated, postsurgical, medication induced, and idiopathic, gastroparesis produces persistent nausea, vomiting, early satiety, bloating, and abdominal pain. The mainstays of therapy are dietary modification, as well as prokinetic and antiemetic medications. However, the progressive nature of gastroparesis in many patients suggests that medically nonresponsive gastroparesis may eventually develop. An array of surgical options exist, but recent endoscopic advances have made the pylorus a therapeutic target to improve gastric emptying. Here reviewed is the anatomic structure and physiologic function of the pylorus. Evidence for endoscopic interventions including balloon dilation of the pylorus, transpyloric stenting, injection of botulinum toxin at the pylorus, and an emerging therapy within the realm of intramural surgery-peroral endoscopic myotomy (POP) are reviewed.


Gastroparesis Pylorus Endoscopy balloon dilation Pneumatic dilation Hydraulic dilation Transpyloric stent Botulinum toxin Peroral endoscopic myotomy (POP) Intramural surgery 


  1. 1.
    Hasler WL. Gastroparesis: symptoms, evaluation, and treatment. Gastroenterol Clin N Am. 2007;36:619–647, ix. Scholar
  2. 2.
    Camilleri M, Bharucha AE, Farrugia G. Epidemiology, mechanisms, and management of diabetic gastroparesis. Clin Gastroenterol Hepatol. 2011;9:5–12.; quiz e7. Scholar
  3. 3.
    Parkman HP, Hasler WL, Fisher RS, American Gastroenterological Association. American Gastroenterological Association medical position statement: diagnosis and treatment of gastroparesis. Gastroenterology. 2004;127:1589–91.CrossRefGoogle Scholar
  4. 4.
    Nguyen LA, Snape WJ. Clinical presentation and pathophysiology of gastroparesis. Gastroenterol Clin N Am. 2015;44:21–30. Scholar
  5. 5.
    Ramkumar D, Schulze KS. The pylorus. Neurogastroenterol Motil. 2005;17(Suppl 1):22–30. Scholar
  6. 6.
    Grover M, Farrugia G, Lurken MS, Bernard CE, Faussone-Pellegrini MS, Smyrk TC, Parkman HP, Abell TL, Snape WJ, Hasler WL, Ünalp-Arida A, Nguyen L, Koch KL, Calles J, Lee L, Tonascia J, Hamilton FA, Pasricha PJ, NIDDK Gastroparesis Clinical Research Consortium. Cellular changes in diabetic and idiopathic gastroparesis. Gastroenterology. 2011;140:1575–1585.e8. Scholar
  7. 7.
    Grover M, Bernard CE, Pasricha PJ, Lurken MS, Faussone-Pellegrini MS, Smyrk TC, Parkman HP, Abell TL, Snape WJ, Hasler WL, McCallum RW, Nguyen L, Koch KL, Calles J, Lee L, Tonascia J, Ünalp-Arida A, Hamilton FA, Farrugia G, NIDDK Gastroparesis Clinical Research Consortium (GpCRC). Clinical-histological associations in gastroparesis: results from the gastroparesis clinical research consortium. Neurogastroenterol Motil. 2012;24:531–539, e249. Scholar
  8. 8.
    Chen JD, Lin Z, Pan J, McCallum RW. Abnormal gastric myoelectrical activity and delayed gastric emptying in patients with symptoms suggestive of gastroparesis. Dig Dis Sci. 1996;41:1538–45.CrossRefGoogle Scholar
  9. 9.
    Koch KL. Chapter 49: gastric neuromuscular function and neuromuscular disorders. In: Sleisenger Fordtrans Gastrointest. Liver Dis. 10th ed: Philadelphia, PA: Saunders Elsevier; 2016. p. 811–38.Google Scholar
  10. 10.
    Faussone-Pellegrini MS, Grover M, Pasricha PJ, Bernard CE, Lurken MS, Smyrk TC, Parkman HP, Abell TL, Snape WJ, Hasler WL, Unalp-Arida A, Nguyen L, Koch KL, Calles J, Lee L, Tonascia J, Hamilton FA, Farrugia G, NIDDK Gastroparesis Clinical Research Consortium (GpCRC). Ultrastructural differences between diabetic and idiopathic gastroparesis. J Cell Mol Med. 2012;16:1573–81. Scholar
  11. 11.
    Mearin F, Camilleri M, Malagelada JR. Pyloric dysfunction in diabetics with recurrent nausea and vomiting. Gastroenterology. 1986;90:1919–25.CrossRefGoogle Scholar
  12. 12.
    Koch KL. Diabetic gastropathy: gastric neuromuscular dysfunction in diabetes mellitus: a review of symptoms, pathophysiology, and treatment. Dig Dis Sci. 1999;44:1061–75.CrossRefGoogle Scholar
  13. 13.
    Ehrenpreis ED, Deepak P, Sifuentes H, Devi R, Du H, Leikin JB. The metoclopramide black box warning for tardive dyskinesia: effect on clinical practice, adverse event reporting, and prescription drug lawsuits. Am J Gastroenterol. 2013;108:866–72. Scholar
  14. 14.
    ASGE Standards of Practice Committee, Fukami N, Anderson MA, Khan K, Harrison ME, Appalaneni V, Ben-Menachem T, Decker GA, Fanelli RD, Fisher L, Ikenberry SO, Jain R, Jue TL, Krinsky ML, Maple JT, Sharaf RN, Dominitz JA. The role of endoscopy in gastroduodenal obstruction and gastroparesis. Gastrointest Endosc. 2011;74:13–21. Scholar
  15. 15.
    Gourcerol G, Tissier F, Melchior C, Touchais JY, Huet E, Prevost G, Leroi AM, Ducrotte P. Impaired fasting pyloric compliance in gastroparesis and the therapeutic response to pyloric dilatation. Aliment Pharmacol Ther. 2015;41:360–7. Scholar
  16. 16.
    Wellington J, Scott B, Kundu S, Stuart P, Koch KL. Effect of endoscopic pyloric therapies for patients with nausea and vomiting and functional obstructive gastroparesis. Auton Neurosci. 2016;202:56. Scholar
  17. 17.
    ASGE Technology Committee, Varadarajulu S, Banerjee S, Barth B, Desilets D, Kaul V, Kethu S, Pedrosa M, Pfau P, Tokar J, Wang A, Song L-MWK, Rodriguez S. Enteral stents. Gastrointest Endosc. 2011;74:455–64. Scholar
  18. 18.
    Clarke JO, Sharaiha RZ, Kord Valeshabad A, Lee LA, Kalloo AN, Khashab MA. Through-the-scope transpyloric stent placement improves symptoms and gastric emptying in patients with gastroparesis. Endoscopy. 2013;45(Suppl 2 UCTN):E189–90. Scholar
  19. 19.
    Khashab MA, Besharati S, Ngamruengphong S, Kumbhari V, El Zein M, Stein EM, Tieu A, Mullin GE, Dhalla S, Nandwani MC, Singh V, Canto MI, Kalloo AN, Clarke JO. Refractory gastroparesis can be successfully managed with endoscopic transpyloric stent placement and fixation (with video). Gastrointest Endosc. 2015;82:1106–9. Scholar
  20. 20.
    Leyden JE, Moss AC, MacMathuna P. Endoscopic pneumatic dilation versus botulinum toxin injection in the management of primary achalasia. Cochrane Database Syst Rev. 2014:CD005046.
  21. 21.
    Montecucco C, Molgó J. Botulinal neurotoxins: revival of an old killer. Curr Opin Pharmacol. 2005;5:274–9. Scholar
  22. 22.
    Vittal H, Pasricha PF. Botulinum toxin for gastrointestinal disorders: therapy and mechanisms. Neurotox Res. 2006;9:149–59.CrossRefGoogle Scholar
  23. 23.
    Ezzeddine D, Jit R, Katz N, Gopalswamy N, Bhutani MS. Pyloric injection of botulinum toxin for treatment of diabetic gastroparesis. Gastrointest Endosc. 2002;55:920–3.CrossRefGoogle Scholar
  24. 24.
    Miller LS, Szych GA, Kantor SB, Bromer MQ, Knight LC, Maurer AH, Fisher RS, Parkman HP. Treatment of idiopathic gastroparesis with injection of botulinum toxin into the pyloric sphincter muscle. Am J Gastroenterol. 2002;97:1653–60. Scholar
  25. 25.
    Lacy BE, Zayat EN, Crowell MD, Schuster MM. Botulinum toxin for the treatment of gastroparesis: a preliminary report. Am J Gastroenterol. 2002;97:1548–52. Scholar
  26. 26.
    Lacy BE, Crowell MD, Schettler-Duncan A, Mathis C, Pasricha PJ. The treatment of diabetic gastroparesis with botulinum toxin injection of the pylorus. Diabetes Care. 2004;27:2341–7.CrossRefGoogle Scholar
  27. 27.
    Bromer MQ, Friedenberg F, Miller LS, Fisher RS, Swartz K, Parkman HP. Endoscopic pyloric injection of botulinum toxin a for the treatment of refractory gastroparesis. Gastrointest Endosc. 2005;61:833–9.CrossRefGoogle Scholar
  28. 28.
    Arts J, van Gool S, Caenepeel P, Verbeke K, Janssens J, Tack J. Influence of intrapyloric botulinum toxin injection on gastric emptying and meal-related symptoms in gastroparesis patients. Aliment Pharmacol Ther. 2006;24:661–7. Scholar
  29. 29.
    Arts J, Holvoet L, Caenepeel P, Bisschops R, Sifrim D, Verbeke K, Janssens J, Tack J. Clinical trial: a randomized-controlled crossover study of intrapyloric injection of botulinum toxin in gastroparesis. Aliment Pharmacol Ther. 2007;26:1251–8. Scholar
  30. 30.
    Revicki DA, Rentz AM, Dubois D, Kahrilas P, Stanghellini V, Talley NJ, Tack J. Gastroparesis cardinal symptom index (GCSI): development and validation of a patient reported assessment of severity of gastroparesis symptoms. Qual Life Res. 2004;13:833–44.CrossRefGoogle Scholar
  31. 31.
    Friedenberg FK, Palit A, Parkman HP, Hanlon A, Nelson DB. Botulinum toxin a for the treatment of delayed gastric emptying. Am J Gastroenterol. 2008;103:416–23. Scholar
  32. 32.
    Bai Y, Xu M-J, Yang X, Xu C, Gao J, Zou D-W, Li Z-S. A systematic review on intrapyloric botulinum toxin injection for gastroparesis. Digestion. 2010;81:27–34. Scholar
  33. 33.
    Clarke JO, Snape WJ. Pyloric sphincter therapy: botulinum toxin, stents, and pyloromyotomy. Gastroenterol Clin N Am. 2015;44:127–36. Scholar
  34. 34.
    Coleski R, Anderson MA, Hasler WL. Factors associated with symptom response to pyloric injection of botulinum toxin in a large series of gastroparesis patients. Dig Dis Sci. 2009;54:2634–42. Scholar
  35. 35.
    Ukleja A, Tandon K, Shah K, Alvarez A. Endoscopic botox injections in therapy of refractory gastroparesis. World J Gastrointest Endosc. 2015;7:790–8. Scholar
  36. 36.
    Toro JP, Lytle NW, Patel AD, Davis SS, Christie JA, Waring JP, Sweeney JF, Lin E. Efficacy of laparoscopic pyloroplasty for the treatment of gastroparesis. J Am Coll Surg. 2014;218:652–60. Scholar
  37. 37.
    Lebaras C, Swanstrom LL. Per-oral Pyloromyotomy (POP): an emerging application of submucosal tunneling for the treatment of refractory gastroparesis. Gastrointest Endosc Clin N Am. 2016;26:257–70. Scholar
  38. 38.
    Hibbard ML, Dunst CM, Swanström LL. Laparoscopic and endoscopic pyloroplasty for gastroparesis results in sustained symptom improvement. J Gastrointest Surg. 2011;15:1513–9. Scholar
  39. 39.
    Hagiwara A, Sonoyama Y, Togawa T, Yamasaki J, Sakakura C, Yamagishi H. Combined use of electrosurgical incisions and balloon dilatation for the treatment of refractory postoperative pyloric stenosis. Gastrointest Endosc. 2001;53:504–8. Scholar
  40. 40.
    Ibarguen-Secchia E. Endoscopic pyloromyotomy for congenital pyloric stenosis. Gastrointest Endosc. 2005;61:598–600.CrossRefGoogle Scholar
  41. 41.
    Kawai M, Peretta S, Burckhardt O, Dallemagne B, Marescaux J, Tanigawa N. Endoscopic pyloromyotomy: a new concept of minimally invasive surgery for pyloric stenosis. Endoscopy. 2012;44:169–73. Scholar
  42. 42.
    Chaves DM, Gusmon CC, Mestieri LHM, de Moura EGH, Veras MM, Pessorrusso FCS, Sakai P. A new technique for performing endoscopic pyloromyotomy by gastric submucosal tunnel dissection. Surg Laparosc Endosc Percutan Tech. 2014;24:e92–4. Scholar
  43. 43.
    Khashab MA, Stein E, Clarke JO, Saxena P, Kumbhari V, Chander Roland B, Kalloo AN, Stavropoulos S, Pasricha P, Inoue H. Gastric peroral endoscopic myotomy for refractory gastroparesis: first human endoscopic pyloromyotomy (with video). Gastrointest Endosc. 2013;78:764–8. Scholar
  44. 44.
    Chaves DM, de Moura EGH, Mestieri LHM, Artifon EL, Sakai P. Endoscopic pyloromyotomy via a gastric submucosal tunnel dissection for the treatment of gastroparesis after surgical vagal lesion. Gastrointest Endosc. 2014;80:164. Scholar
  45. 45.
    Shlomovitz E, Pescarus R, Cassera MA, Sharata AM, Reavis KM, Dunst CM, Swanström LL. Early human experience with per-oral endoscopic pyloromyotomy (POP). Surg Endosc. 2015;29:543–51. Scholar
  46. 46.
    Gonzalez J-M, Lestelle V, Benezech A, Cohen J, Vitton V, Grimaud J-C, Barthet M. Gastric per-oral endoscopic myotomy with antropyloromyotomy in the treatment of refractory gastroparesis: clinical experience with follow-up and scintigraphic evaluation (with video). Gastrointest Endosc. 2016;85:132. Scholar
  47. 47.
    Mekaroonkamol P, Li LY, Dacha S, Xu Y, Keilin SD, Willingham FF, Cai Q. Gastric peroral endoscopic pyloromyotomy (G-POEM) as a salvage therapy for refractory gastroparesis: a case series of different subtypes. Neurogastroenterol Motil. 2016;28:1272–7. Scholar
  48. 48.
    Khashab MA, Ngamruengphong S, Carr-Locke D, Bapaye A, Benias PC, Serouya S, Dorwat S, Chaves DM, Artifon E, de Moura EG, Kumbhari V, Chavez YH, Bukhari M, Hajiyeva G, Ismail A, Chen Y-I, Chung H. Gastric per-oral endoscopic myotomy for refractory gastroparesis: results from the first multicenter study on endoscopic pyloromyotomy (with video). Gastrointest Endosc. 2016;85:123. Scholar
  49. 49.
    Gonzalez J-M, Vanbiervliet G, Vitton V, Benezech A, Lestelle V, Grimaud J-C, Barthet M. First European human gastric peroral endoscopic myotomy, for treatment of refractory gastroparesis. Endoscopy. 2015;47(Suppl 1 UCTN):E135–6. Scholar

Copyright information

© SAGES 2019

Authors and Affiliations

  1. 1.Department of General SurgeryCleveland ClinicClevelandUSA
  2. 2.Digestive Disease Institute, Cleveland Clinic Lerner College of Medicine, Department of General Surgery, Cleveland ClinicAbu DhabiUnited Arab Emirates

Personalised recommendations