Gastric per-oral endoscopic myotomy (G-POEM) for the treatment of gastric sleeve stenosis: a feasibility and safety study

Abstract

Background/aims: Traditional endoscopic treatments have limited success for treatment of gastric sleeve stenosis (GSS). Gastric peroral endoscopic myotomy (G-POEM) could conceivably obliterate the twist/angulation that causes GSS through a tunneled stricturotomy (instead of pyloromyotomy). We report early outcomes of G-POEM for GSS treatment. Methods: We retrospectively reviewed all patients with GSS treated with G-POEM at a single center. The primary endpoint was clinical success, defined as symptom improvement with resumption of adequate oral intake, without requiring further intervention. Results: 13 patients (12 female, mean age 43±10.9 years) underwent G-POEM for predominantly helical (n=11, 85%) GSS. Three (23%) had concurrent sleeve leak and ten (77%) had prior GSS treatment. There were two intraoperative AEs resulting in no deviation to the procedure. No major AEs occurred. At a median 175 (IQR119-260) days follow up, clinical success was achieved in 10 patients (77%). Median GCSI score in responders decreased post-G-POEM from 2.06 (IQR1.5-2.8) to 0.39 (IQR0.2-0.5). Three patients (23%) required surgical revision. Conclusions: G-POEM is a feasible and safe technique which may provide an alternative option for those averse to undergoing surgical revision for treatment of GSS.

Third-space endoscopy to the rescue: what is the role of gastric peroral endoscopic myotomy in the management of gastric sleeve stenosis?

“…Clinical success was defined as symptomatic improvement with adequate oral intake and no further interventions required [5]. With a median follow-up of 5.8 months (range 4-8.7 months), 10/13 cases were defined as successful: 6/13 had complete symptom resolution, 4/13 were deemed partial responders, and 3/13 required salvage Roux-en-Y gastric bypass (RYGB) for persistent symptoms.…”

“…Another contentious issue is the quantification of successful response to treatment in GSS. As no validated outcome tools exist, the authors used the Gastroparesis Cardinal Symptom Index (GCSI) score in their analysis [5]. As correctly emphasized by the authors, the GCSI score is not ideal for GSS outcome assessment [5].…”

“…In this issue of Endoscopy, Zhang et al [5] describe the results of gastric peroral endoscopic myotomy (G-POEM) in 13 GSS cases. Their efforts to classify cases as helical (axial deviation) and nonhelical (straight staple line) GSS and to analyze their outcomes independently must be commended.…”

“…As no validated outcome tools exist, the authors used the Gastroparesis Cardinal Symptom Index (GCSI) score in their analysis [5]. As correctly emphasized by the authors, the GCSI score is not ideal for GSS outcome assessment [5]. This article highlights the deficiency and clear need for future validated questionnaires to adequately assess GSS severity and response to treatment.…”

“…An interesting avenue of future research is the potential use of impedance planimetry in the diagnosis, confirmation of adequate myotomy, or even as a predictor of treatment response [7]. In the Zhang et al article, the authors describe a rather long full-thickness myotomy, with a median length of 8 cm [5]. Future studies aimed at determining the optimal length of myotomy (and possibly its orientation) are required, while ac-knowledging that such an entity would be difficult to define given the variability in GSS configuration.…”