Gastric Per Oral Endoscopic Myotomy (G-POEM) for the Treatment of Refractory Gastroparesis: Early Experience

Abstract

G-POEM for treatment of refractory gastroparesis appears to be a feasible and safe technique that can be successfully performed in patients with a variety of etiologies including different types of postsurgical gastroparesis. Our initial experience suggests that the majority of patients report some improvement in symptoms, particularly symptoms of vomiting, retching, and loss of appetite. Further experience is needed to determine the efficacy and safety of G-POEM and predict those who best respond to this treatment.

Outcomes of per oral endoscopic pyloromyotomy in gastroparesis worldwide

“…Generous irrigation should be exercised to clean the stomach content and mucosotomy site. Gentamycin rinse was advocated by some centers[47]. Other technical variations among endoscopists include site of mucosal entry (lesser vs greater curve), mucosotomy closure tools (clips vs suture), depth of pyloromyotomy, and the need for fluoroscopy[2,45,50-52].…”

“…In the early studies, mucosal entry was performed mainly on the greater curve or anterior wall of the stomach and full thickness myotomy was reported[37,53,54]. However, subsequent studies verified that submucosal tunnel can be safely and effectively performed regardless of the site of mucosal entry and selective circular myotomy can achieve clinical success without the perforation risk in full thickness myotomy[41,47,48,55,56]. While mucosotomy on the greater curve makes the scope more in a neutral position and allows greater maneuverability, performing a mucosal entry on the lesser curve has its own advantages that are: (1) Shorter scope length to mucosotomy site by minimizing the gastric loop; (2) shorter length of the submucosal tunnel, reducing the risk of tunneling in the wrong direction; and (3) the procedural field is not a dependent area when the patient is on supine position, therefore blood and food would not interfere with the endoscopic visualization[48,49,55].…”

“…Across all publications, 291 patients underwent POP[2,37,41,43,45,47,48,55,56,58,59,61,62]. Etiology of gastroparesis were diabetes ( n = 69), post-surgery ( n = 61), idiopathic ( n = 93), post-infection ( n = 1), and other causes ( n = 10), which included systemic sclerosis, Sjogren syndrome, and Ehlers Danlos syndrome as described in Table 1.…”

Pathophysiology of idiopathic gastroparesis and implications for therapy

“…Gastric per oral endoscopic myotomy (POP) is another promising treatment which can be used to cleave the pylorus [85]. In retrospective open label studies of mixed etiology gastroparesis cohorts, POP is safe and effective at reducing 4-hour GES and most symptoms of gastroparesis [85][86][87][88][89]. In one study, POP was as effective as laparoscopic pyloroplasty (PP) at reducing symptoms and gastric emptying time, but resulted in less complications, a shorter length of hospital stay and had a shorter operation time [87].…”

G-POEM for Gastroparesis: Is There Pressure to Go with the Flow?

“…In this issue of Digestive Diseases and Sciences, Malik et al [6] report their experience with G-POEM in 13 gastroparesis patients. At first glance, the results appear promising.…”