Gastric outlet obstruction caused by vanishing pylorus following gastric peroral endoscopic myotomy

Gastric peroral endoscopic pyloromyotomy (G-POEM) is used to manage gastroparesis that is refractory to conventional therapies [1] [2]. Long-term data suggest high overall clinical success (77.5%), with higher success for diabetic gastroparesis (86.5%) [3]. Additionally, the safety of G-POEM has been established, with a very small risk of serious adverse events [4].

A 68-year-old woman with idiopathic gastroparesis, for which medical and endoscopic therapy had failed, underwent G-POEM ([Fig. 1]). She was discharged 1 day after the procedure with a liquid diet and twice-daily proton pump inhibitor (PPI). She presented to the emergency department 2 days later with nausea, vomiting, and abdominal pain. Initial vital signs and laboratory blood testing were normal. Subsequent computed tomography scan showed a distended, fluid-filled stomach with radiological evidence of gastric outlet obstruction (GOO) ([Fig. 2]). A nasogastric tube was placed for gastric decompression.

Fig. 1 Endoscopic images. a Before gastric peroral endoscopic pyloromyotomy (G-POEM). b After G-POEM.

Fig. 2 Computed tomography image (coronal) showing the distended, fluid-filled stomach.

Repeat endoscopy was performed, the open mucosotomy was identified, and the tunnel was accessed. There were signs of epithelialization of the submucosa, suggestive of healing. On initial inspection, the pylorus was not visible; however, with careful examination, a pinpoint opening was found and deemed to be the pyloric rim ([Fig. 3] a). A guidewire was advanced into duodenum under fluoroscopic guidance. A 15 × 15 mm lumen-apposing metal stent (LAMS) was placed over the guidewire ([Fig. 3] b). The tunnel was re-accessed, and a hemostatic agent was applied ([Fig. 4]). The patient was able to tolerate liquid and was discharged the following day on PPI therapy and dietary instruction ([Video 1]).

Fig. 3 Endoscopic images. a Severely stenosed pylorus after gastric peroral endoscopic pyloromyotomy. b A lumen-apposing metal stent was placed.

Fig. 4 Placement of hemostatic agent within the submucosal tunnel.

Gastric outlet obstruction caused by vanishing pylorus following gastric peroral endoscopic myotomy.Video 1

GOO following G-POEM is rare and has not been described in the literature. Post-procedural inflammation with pyloric edema is a possible etiology in the current case. Careful examination to rule out other etiologies such as accidental suturing of the pylorus during mucosotomy closure is crucial. LAMS placement allows for immediate relief of obstruction and can be subsequently removed after inflammation subsides.

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Publikationsverlauf

Artikel online veröffentlicht:
04. September 2025

• References

• 1 McCurdy GA, Gooden T, Weis F. et al. Gastric peroral endoscopic pyloromyotomy (G-POEM) in patients with refractory gastroparesis: a review. Therap Adv Gastroenterol 2023; 16: 17562848231151289
• 2 Mekaroonkamol P, Shah R, Cai Q. Outcomes of per oral endoscopic pyloromyotomy in gastroparesis worldwide. World J Gastroenterol 2019; 25: 909-922
• 3 Hernández Mondragón OV, Contreras LFG, Velasco GB. et al. Gastric peroral endoscopic myotomy outcomes after 4 years of follow-up in a large cohort of patients with refractory gastroparesis (with video). Gastrointest Endosc 2022; 96: 487-499
• 4 Baret F, Jacques J, Pioche M. et al. Evaluation of the safety profile of endoscopic pyloromyotomy by G-POEM: a French multicenter study. Therap Adv Gastroenterol 2022; 15: 17562848221122472