Delayed gastric conduit emptying (DGCE) affects 15–39% of patients after esophagectomy,
increasing the risk of aspiration, pneumonia, and malnutrition [1]. “Sump” formation with chronic dilation often necessitates surgical intervention.
Per-Oral Plication of the neo-Esophagus (POPE) is a novel endoscopic technique adapted
from
endoscopic sleeve gastroplasty (ESG) to remodel the neo-esophagus (and end-stage achalasia
megaesophagus) and improve emptying [2], with 82.3% symptom improvement, although 23.5% requiring repeat intervention.
Studies of ESG have shown that 83.64% of sutures persist at 12 months, with 70.9%
maintaining adequate tension [3]. Combining mucosal denudation techniques like argon plasma coagulation (APC) or
endoscopic mucosal resection (EMR) may enhance submucosa to submucosa apposition leading
to better suture retention and durability [4]
[5].
We present a modified POPE by combining mucosal denudation techniques, to address
sump-related retention and improve gastric emptying in a patient with refractory DGCE
([Video 1]).
Modified Per-Oral Plication of the (Neo)Esophagus (POPE) for refractory delayed gastric
conduit emptying.Video 1
A 72-year-old woman with esophageal adenocarcinoma underwent partial esophagectomy
with gastric conduit reconstruction in 2019. She developed early satiety, worsening
heartburn when supine, and progressive oral intolerance, necessitating total parenteral
nutrition. Imaging confirmed a neo-esophageal sump with significant retention. Dietary
adjustments, prokinetics, and pyloric botulinum toxin injection failed, with worsening
symptoms and bile reflux. A multidisciplinary team recommended POPE for sump remodeling.
Modified POPE was performed under general anesthesia in the supine position, using
a suturing device without an overtube, combining with EMR and APC. Endoscopic and
radiologic assessment confirmed improved conduit alignment and pyloric passage ([Fig. 1]). The patient was discharged after 48 hours without complications and tolerating
diet. At a 4-month follow-up, endoscopy confirmed sustained remodeling with symptom
improvement and no retention. In conclusion, modified POPE is a feasible, minimally
invasive technique for refractory DGCE due to sump formation. Further studies are
needed to evaluate long-term efficacy.
Fig. 1 Esophagogram previous to the intervention on the left; esophagogram after POPE on
the right. Abbreviation: POPE, per-oral plication of the (neo)esophagus.
Endoscopy_UCTN_Code_TTT_1AO_2AP
E-Videos is an open access online section of the journal Endoscopy, reporting on interesting cases and new techniques in gastroenterological endoscopy.
All papers include a high-quality video and are published with a Creative Commons
CC-BY license. Endoscopy E-Videos qualify for HINARI discounts and waivers and eligibility is automatically checked during the submission
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