Gastric per-oral endoscopic myotomy: Current status and future directions

Abstract

Gastroparesis, or symptomatic delayed gastric emptying in the absence of mechanical obstruction, is a challenging and increasingly identified syndrome. Medical options are limited and the only medication approved by the Food and Drug Administration for treatment of gastroparesis is metoclopramide, although other agents are frequently used off label. With this caveat, first-line treatments for gastroparesis include dietary modifications, antiemetics and promotility agents, although these therapies are limited by suboptimal efficacy and significant medication side effects. Treatment of patients that fail first-line treatments represents a significant therapeutic challenge. Recent advances in endoscopic techniques have led to the development of a promising novel endoscopic therapy for gastroparesis via endoscopic pyloromyotomy, also referred to as gastric per-oral endoscopic myotomy or per-oral endoscopic pyloromyotomy. The aim of this article is to review the technical aspects of the per-oral endoscopic myotomy procedure for the treatment of gastroparesis, provide an overview of the currently published literature, and outline potential next directions for the field.

United European Gastroenterology (UEG) and European Society for Neurogastroenterology and Motility (ESNM) consensus on gastroparesis

“…endoscopic myotomy or (partial) gastrectomy. [95][96][97][98][99][100][101][102][103][104][105][106][107][108][109][110][111][112][113] There is agreement on the use of nutritional support in case of severe weight loss. 44,71,[119][120][121] Finally, there is consensus that the long-term prognosis of gastroparesis depends on the cause, but there is no consensus on an unfavorable long-term prognosis or increased mortality.…”

The functional lumen imaging probe in gastrointestinal disorders: the past, present, and future

“…Specifically, the assessment of pyloric distensibility has shown promise as a potential means of selecting patients who may have functional gastric outflow obstruction and may benefit from pyloric intervention, especially given the burgeoning interest in gastric per-oral endoscopic myotomy (G-POEM) across the world and the limited treatment options currently available for gastroparesis. 50,51 In a seminal study showing proof of principle, Gourcerol and colleagues evaluated pyloric FLIP in 27 gastroparesis patients versus 21 controls. They reported that 10 out of 26 gastroparesis patients had reduced pyloric compliance and that there was a significant symptom improvement noted in patients with reduced pyloric compliance who underwent pyloric balloon dilation.…”

“…As FLIP was initially developed for the evaluation of the EGJ, most of the research to date has focused on the esophagus; however, there is emerging interest in utilizing FLIP to assess other sphincters in the gastrointestinal system. Specifically, the assessment of pyloric distensibility has shown promise as a potential means of selecting patients who may have functional gastric outflow obstruction and may benefit from pyloric intervention, especially given the burgeoning interest in gastric per‐oral endoscopic myotomy (G‐POEM) across the world and the limited treatment options currently available for gastroparesis 50,51 …”

The Optimal Pyloric Procedure: A Collective Review

“…Moreover, as the function of esophageal conduits changes over time after surgery, different results may be obtained depending on the evaluation period [ 4 , 6 , 26 ]. Finally, endoscopic techniques (EBD, BT, and even PM) [ 14 - 16 , 30 , 33 , 34 ] can be used for DGE or GOO, with different outcomes. As such, there is difficulty in controlling for these numerous variables to identify the optimal pyloric procedure.…”

“…Historically, PM was performed under laparotomy, but it was adapted to laparoscopy [10][11][12][13]. Recently, new and less invasive methods have been described, including a report stating that gastric per-oral endoscopic PM was a useful and safe method [14][15][16][17].…”