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.
Endoscopy_UCTN_Code_CPL_1AH_2AJ
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