GASTRIC PER ORAL ENDOSCOPIC PYLOROMYOTOMY AS A TREATMENT FOR GASTROPARESIA

Gastroparesis is a frequent and chronic disorder associated with high morbidity, reduced quality of life. Most of the current pharmacotherapies aim to stimulate gastric motility however they show limited results and significant safety risks. Other therapies aim to diminish pyloric tone, as such, botulinum toxin has been proposed, however recent controlled trials did not find any difference compared to placebo. Based on the results of pyloric aimed therapies and the growth of submucosal endoscopy, endoscopic pyloromyotomy has been proposed and 2 uncontrolled retrospective studies have shown encouraging results.

We describe the case of a 59 year old woman with a past medical history of squamous cell esophageal carcinoma treated neo-adjuvant radio-chemotherapy followed by surgical resection with esophago-gastric anastomosis. Nine months later the patient presented postprandial vomiting and weight loss. Gastroscopy showed normal anastomosis and gastric stasis. Isotopic gastric emptying study showed a pylorospasm, delayed gastric emptying at 410 min (normality defined by 30 – 70 min). The patient is considered for gastric per oral pyloromyotomy.

The procedural steps will be as follows:

1. submucosal injection and mucosal incision on the posterolateral part of the antrum, at the 5 o'clock position and 3 to 4 cm upstream from the pylorus;

2. tunnel access and creation by submucosal dissection up to the pyloric area identified by the characteristic white muscle fiber pyloric arch at the 6 o'clock position;

3. myotomy of circular and longitudinal muscular layers of the pylorus and the antrum 3 cm long and deep up to the serosa; and

4. mucosal closure using endoclips.

G-POEM is a safe and minimally invasive technique which might be an alternative treatment in patients gastroparesis refractory to medical management. Further studies and particularly controlled trials are needed to determine the role of this procedure.