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Per-oral Endoscopic Pyloromyotomy for Gastroparesis

Reggie Nichols PA-SII

The Case

The Case

Ms. Diane Betes, 60 YOF with 23 year h/o type 2

DM, presents complaining of persistent nausea and vomiting for the last 6 months stating she "can't keep anything down." Most recent HbA1c reported to be "about 8." Reports passing gas, but states her "bowel movements have been very few and far between, but loose when they do come along." Endorses 10 lbs weight loss during this time. Denies hematemasis, heartburn, fever. Denies any aggravating factors. Describes emesis as consiting of "whatever I just ate."

Denies family history of cancer. Is a lifelong non-

smoker. States she is coming in now as she

"fears losing too much weight." States that

this has happened before, but that it

resolved with diet changes.

Workup

The Workup

Risk Factors for Gastroparesis - Female, DM

Rule out mechanical factors - U/S, Scintigraphy

Ultrasound reveals no mass

Scintigraphy shows >70% of radiolabelled meal in stomach after 2 hours, and >35% after 4 hours

The Significance

Gastroparesis is multifactorial, debilitating, and potentially life-threatening if left untreated. When due to an underlying neuropathy, treatment can be especially tricky.

The Significance

1, 3

1, 4

Pathophysiology

Interstitial Cells of Cajal dysfunction

Pyloric obstruction

Pathophysiology

Nitric oxide synthesis/release defect

Parasympathetic dysfunction with Vagus Nerve injury

1, 3, 4

Complications

Complications

Malnutrition

Bezoars

Dehydration

Electrolyte disturbances

Hyper/hypoglycemia

4, 5

Treatment Options

The Options

Conservative:

Dietary modifications (Liquid, Soft Foods)

Prokinetic agents (Metoclopramide, Erythromycin, Domperidone)

Surgical:

Intramuscular pyloric botulinum toxin injections

Gastric electrical stimulation

Transpyloric stenting

Gastrostomy tube insertion

Pyloromyotomy

Gastrectomy

The Case Revisited

Ms. Betes

What Ms. Betes has to say about these options:

"I've already changed my diet and Metoclopramide never worked for me before. I also heard that it gives you Parkinsons!"

"I don't want botox, that's toxic."

"Gastric pacemaker? I already have a cardiac pacemaker? Will they conflict? I don't feel comfortable with that."

"I don't like surgery. I don't want to be cut open. Is there some other way?"

6

G-POEM

2013 - First performed at John Hopkins

Modified POEM, for gastroparesis

instead of achalasia, consisting of 4 steps:

1. Mucosal incision - 5cm proximal to pylorus along

greater curvature

Mucosal bleb raised using 0.01% Epi and 0.25% indigo carmine in 0.9% saline

Recommend HybridKnife (water injection and electrocautery)

2. Submucosal tunnel creation - Spray coagulation with repeated blebing to enhance layer separation

Extends until visualization of pyloric muscle fibers

3. Myotomy - Selective myotomy of inner muscle fibers

Reduce risk of entering abdominal space

Circular muscle bundles are lifted towards submucosal tunnel by knife tip and divided with spray coagulation at 50 watts

4. Mucosal Closure - Endoscopic clips or endoluminal

suturing (via OverStitch)

POP (G-POEM)

Post-Op

Post-Op Care (not standardized):

NPO overnight with prophylactic antibiotics and antiemetics

Barium swallow the next day to exclude leak

Pending swallow eval, soft diet is allowed and encouraged for 10-14 days postop

Pictures!

1, 5, 7

Adverse Outcomes

207 patients across 8 studies

Upper GI Bleeding - 2

Peptic Ulceration - 4

Capnopertineum - 7

Abscess - 2

Pulmonary Embolism - 1

The Risks

1, 2, 5, 7

Overall Results

The Results

100% technical success across all 207 patients.

Clinical success rate averaged at ~81%.

Predicted probability for dysphagia improvement after 12 months greater than traditional pyloromyotomy

Average procedural time was 53 minutes.

Average hospital stay was 2.9 days (range 1-5.4 days)

Longer than traditional pyloromyotomy (by 1 day)

Conclusion

7

4, 5

Conclusion

"The G-POEM technique has been successfully used to treat ... severe gastroparesis refractory to medical therapy."

Early retrospective studies look encouraging.

Despite this, more long-term studies are necessary to confirm results and establish guideline

recommendations that are standardized to

ensure safe practice.

1, 4, 5

References

References

1. Chung, Khashab. "Gastric Peroral Endoscopic Myotomy." 2018. Clin Endosc. 51(1):28-32.

2. Jacques et al. "Peroral Endoscopic Pyloromyotomy

is Efficacious and Safe for Refractory Gastroparesis." 2018. Endoscopy. DOI: 10.1055/a-0628-6639.

3. Kalaleh et al. "Gastric Peroral Endoscopic Myotomy for the Treatment of Refractory Gastroparesis." 2018. DOI: 10.1055/a-0596-7199.

4. Khoury et al. "State of the Art Review with Literature Summary on Gastric Peroral Endoscopic Pyloromyotomy for Gastroparesis." 2018. Journal of Gastroenterology

and Hepatology.

5. Su et al. ""Endoscopic Therapies for Gastroparesis." 2018. Current Gastroenterology Reports.

6. Khashab et al. "G-POEM for Refractory Gastroparesis:

First Human Endoscopic Pyloromyotomy." 2013. GIE

Journal.

7. UpToDate

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