Per-Oral Endoscopic Pyloromyotomy in a Patient with History of Sleeve Gastrectomy: A Promising Intervention for Gastroparesis?

Abstract

Introduction:

Gastroparesis is defined as delayed gastric emptying in the absence of mechanical gastric outlet obstruction. The gastroparesis cardinal symptom index (GCSI) measures symptom severity and can be used to monitor outcomes after treatment. The GCSI includes nine different symptoms related to nausea, vomiting, fullness, early satiety, bloating, and distension, with higher numbers correlating with higher severity. ¹ There are various treatment modalities for medically refractory gastroparesis, such as per-oral endoscopic pyloromyotomy (POP), which involves an endoscopic submucosal tunneling technique to divide the circular muscle fibers of the pylorus. ² In patients with normal gastric anatomy, success rates have been quoted upward of 90% with comparable efficacy to laparoscopic pyloroplasty. ³ It remains unclear whether the benefits of per-oral endoscopic pyloromyotomy can be extrapolated to patients with altered upper gastrointestinal (GI) anatomy, such as after bariatric surgery. ⁴

Materials and Methods:

This is a 61-year-old female who presented with persistent reflux-type symptoms after undergoing sleeve gastrectomy and paraesophageal hernia repair 2 years before presentation. Her initial GCSI score was 29. Her upper GI swallow study showed normal esophageal motility without stricture or dilation. Her gastric emptying study demonstrated delayed gastric emptying with only 71% emptying at 4 hours. She was considered for conversion to gastric bypass but was referred to our endoscopic surgery service for a POP procedure after she expressed concerns regarding exacerbation of her dysphagia. In the operating room, the pylorus was noted to be quite tight on endoscopy, such that it would require a fair amount of pressure to advance the gastroscope. A submucosal bleb was created with a mixture of saline and methylene blue on the lesser curve of the stomach, ∼2–3 cm away from the pylorus. Of note, this was a fairly difficult angle to access secondary to the sleeve anatomy. Using a triangle tip knife, a mucosotomy was performed and the dissection through the submucosal tunnel was carried down to expose the pylorus muscle. As the angle of dissection from the sleeve gastrectomy was not ideal for a complete myotomy, a partial myotomy was performed instead. The gastroscope then easily advanced into the duodenum where as previously it had been more difficult. The mucosotomy was closed with serial firings of five through-the-scope clips.

Results:

At 1 month follow-up, her GCSI improved from 29 to 9. She was maintained on a proton pump inhibitor and sucralfate for 6 weeks postprocedure and advised to continue to follow a gastroparesis diet consisting of low fat and low fiber small frequent meals.

Conclusion:

Although her history of a sleeve gastrectomy added an extra layer of difficulty to the procedure, the POP procedure was safe and effective in reducing her gastroparesis symptoms. To date, no other similar procedures have been performed by our department in other patients. Further study is necessary to establish the safety and efficacy of this procedure before its implementation as standard practice for gastroparesis in patients with altered upper gastrointestinal anatomy.

A.H. and D.J.M. have no financial disclosures. J.S.W. is a consultant for Boston Scientific Co.

Runtime of video: 5 mins 27 secs

Acknowledgment:

The source of the study is the Department of Minimally-Invasive Surgery at Penn State Milton S. Hershey Medical Center.

Patient Consent:

Author(s) have received and archived patient consent for video recording/publication in advance of video recording of procedure.

This video was presented as a video presentation at the 2022 Society of Gastrointestinal and Endoscopic Surgery on March 17, 2022.