Gastric peroral endoscopic myotomy versus botulinum toxin injection for the treatment of refractory gastroparesis: results of a double-blind randomized controlled study.

INTRODUCTION: Gastric peroral endoscopic myotomy (G-POEM) is a promising technique for treating refractory gastroparesis. We present the first double-blind randomized study comparing the clinical efficacy of G-POEM versus pyloric botulinum toxin injection (BTI). METHODS: This randomized study, conducted in two expert centers, enrolled patients with refractory gastroparesis, medically managed for >6 months and confirmed by gastric emptying scintigraphy (GES), into two groups, G-POEM versus BTI, with follow-up of 1 year. The primary end point was the 3-month clinical efficacy, defined as a >1-point decrease in the mean Gastroparesis Cardinal Symptom Index (GCSI) score. Secondary end points were: 1-year efficacy, GES evolution, adverse events, and quality of life. RESULTS: 40 patients (22 women; mean age 48.1 [SD 17.4]), with mean symptom duration of 5.8 (SD 5.7) years, were randomized. Etiologies included idiopathic (n=18), diabetes (n=11), postoperative (n=6), and mixed (n=4). G-POEM showed a higher 3-month clinical success than BTI (65% vs. 40%, respectively; P=0.10), along with non-significantly higher 1-year clinical success (60% vs. 40%, respectively) on intention-to-treat analysis. The GCSI decreased in both groups at 3 months and 1 year. Only three minor adverse events occurred in the G-POEM group. The GES improvement rate was 72% in the G-POEM group versus 50% in the BTI group (non-significant). CONCLUSION: G-POEM seems to have a higher clinically relevant success rate than BTI, but this was not statistically demonstrated. This study confirms the interest in treatments targeting the pylorus, either mechanically or chemically, for managing refractory gastroparesis.

Gastric Peroral Endoscopic Pyloromyotomy for Infants With Congenital Hypertrophic Pyloric Stenosis.

INTRODUCTION: Congenital hypertrophic pyloric stenosis (CHPS), the most common infantile disease requiring surgical intervention, is routinely treated with open or laparoscopic pyloromyotomy. Recently, gastric peroral endoscopic pyloromyotomy (G-POEM) has been used for adult gastroparesis. We aimed to evaluate the efficacy and safety of G-POEM in treating infantile CHPS. METHODS: We reviewed data from 21 G-POEM-treated patients at 3 tertiary children's endoscopic centers in China between January 2019 and December 2020. Clinical characteristics, procedure-related parameters, perioperative management, and follow-up outcomes were summarized. RESULTS: G-POEM was performed successfully in all patients. The median operative duration was 49 (14-150) minutes. The submucosal tunnels were successfully established along the greater curvature of the stomach in 19 cases, and 2 cases were switched to the lesser curvature because of difficulty. No perioperative major adverse events occurred. Minor adverse events included inconsequential mucosal injury in 5 cases and unsatisfactory closure of the mucosal incision in 1 case. Upper gastrointestinal contrast radiography in all patients showed smooth passage of the contrast agent through the pylorus on postoperative day 3. The growth curves of the patients reached normal levels 3 months after the procedure. No recurrent clinical symptoms occurred in any patient during the median follow-up period of 25.5 (14-36) months. DISCUSSION: G-POEM is feasible, safe, and effective for infants with CHPS, with satisfactory clinical responses over a short-term follow-up. Further multicenter studies should be performed to compare the long-term outcomes of this minimally invasive technique with open or laparoscopic pyloromyotomy.

Gastric per-oral endoscopic myotomy versus pyloric injection of botulinum toxin for the treatment of gastroparesis: our institutional experience and a systematic review of the literature.

INTRODUCTION: Gastric Per-Oral Endoscopic Myotomy (GPOEM) has been developed as an effective treatment option for patients with medically refractory gastroparesis. Other endoscopic options, such as pyloric injection of botulinum toxin (Botox), is often performed with limited efficacy. The purpose of this study was to evaluate GPOEM for the treatment of gastroparesis and compare its efficacy to Botox injection results reported in the literature. METHODS: A retrospective review was conducted to identify all patients who underwent a GPOEM for the treatment of gastroparesis between September 2018 and June 2022. Changes in Gastric Emptying Scintigraphy (GES) studies and Gastroparesis Cardinal Symptom (GCSI) scores from the preoperative to postoperative period were analyzed. In addition, a systematic review was conducted to identify all publications reporting the outcomes of Botox injections for the treatment of gastroparesis. RESULTS: A total of 65 patients (51 female, 14 male) underwent a GPOEM during the study period. Twenty-eight patients (22 female, 6 male) had both preoperative and postoperative GES studies in addition to GCSI scores. The etiologies of gastroparesis were diabetic (n = 4), idiopathic (n = 18), and postsurgical (n = 6). Fifty percent of these patients had undergone previous failed interventions including Botox injections (n = 6), gastric stimulator placement (n = 2), and endoscopic pyloric dilation (n = 6). Outcomes showed a significant decrease in GES percentages (mean difference = - 23.5%, p < 0.001) and GCSI scores (mean difference = - 9.6, p = 0.02) postoperatively. In the systematic review for Botox, transient mean improvements in postoperative GES percentages and GCSI scores were reported at 10.1% and 4.0, respectively. CONCLUSION: GPOEM leads to significant improvement in GES percentages and GCSI scores postoperatively and is superior to Botox injection results reported in the literature.

[S156] Comparing outcomes of per-oral pyloromyotomy and robotic pyloroplasty for the treatment of gastroparesis.

BACKGROUND: Gastroparesis is characterized by delayed gastric emptying without a significant obstructive pathology and is estimated to effect more than 5 million adults in the United States. Therapies for this condition are divided into two categories: gastric electrical stimulation or pyloric therapies to facilitate gastric emptying. Pyloric procedures include pyloroplasty, a well-documented procedure, and per-oral endoscopic myotomy (POP), a relatively novel endoscopic procedure that disrupts the pyloric muscles endoscopically. There is a paucity of literature comparing the two procedures. The aim of this study is to compare the outcomes of these two techniques. METHODS: Under an IRB protocol, data were collected prospectively from September 2018 through April 2021 at our institution for patients undergoing POP (n = 63 patients) or robotic pyloroplasty (RP) (n = 48). Preoperative and postoperative data including sex, race, age, BMI, and Gastroparesis Cardinal Symptom Index (GCSI) score were analyzed using univariate and multivariate analysis. RESULTS: There was no significant difference in sex, age, and BMI for both cohorts, but patients with RP were more likely to have private insurance, pre-op reflux, and PPI (p < .05 for all). Patients who underwent POP had significantly shorter operative time compared to RP (median 27 min vs 90, p < 0.001). The average change between preoperative and postoperative GCSI scores was significantly decreased for both interventions (POP mean = 8.2, RP 16.8, p < 0.001 both). However, comparing both data, RP has significantly better improvement in postoperative GCSI score than POP in both univariate (p < 0.001) and multivariate analysis (p = 0.030). This was reflected in the individual symptoms with nausea (p < 0.001), ability to finish meal (p = 0.037), abdomen visibly larger (p = 0.037) and bloating (p = 0.022) all showing improvement in both groups, but with RP having a more significant decrease in the scoring of these symptoms than POP. There was no significant difference in the number of postoperative complications (POP 19% vs RP 13%, p = 0.440). CONCLUSION: Even though both interventions are significantly associated with improvement of symptoms in patients with gastroparesis, our data demonstrates that robotic pyloroplasty has a superior response in comparison to per-oral endoscopic myotomy for the management of these symptoms. Per-oral pyloromyotomy has a similar complication rate to robotic pyloroplasty with a shorter operative time.

Significant changes in impedance planimetry (EndoFLIP™) measurements after peroral pyloromyotomy for delayed gastric emptying.

BACKGROUND: The endoluminal functional lumen imaging probe (FLIP) can be used to obtain real-time measurements of the diameter (Dmin), cross-sectional area (CSA), and distensibility of the pylorus before and after peroral pyloromyotomy (POP), an emerging endoscopic treatment for delayed gastric emptying. Our study aims to report our single-center experience in performing POP with FLIP measurements before and after pyloromyotomy. METHODS: A retrospective review of a prospectively maintained gastroesophageal database was performed. Demographic and perioperative data, including intraoperative FLIP measurements of the pylorus before and after POP, were analyzed. Measurements were compared using paired t tests. RESULTS: Thirty-four patients underwent POP between February 2017 and July 2020. Twenty-three (67.7%) patients were male and the average age was 59 years. The etiology of delayed gastric emptying was post-vagotomy in 22 patients, idiopathic gastroparesis in 7 patients, and diabetic gastroparesis in 5 patients. There were no significant differences in pre-myotomy or post-myotomy FLIP measurements when comparing the post-vagotomy versus the gastroparesis groups. There were significant increases in Dmin, CSA, and distensibility index when comparing pre-myotomy and post-myotomy readings for all patients (all p < 0.001). At follow-up, 64.7% of patients reported resolution of all symptoms. CONCLUSION: POP is an effective intervention in patients with delayed gastric emptying. Significant changes in FLIP measurements before and after POP suggest that FLIP may be a useful adjunct in guiding the management of delayed gastric emptying.

Real-time intraoperative functioning lumen imaging probe during endoscopic per-oral pyloromyotomy (pop).

BACKGROUND: Endoscopic per-oral pyloromyotomy (POP) has emerged as a safe and effective first line option in medically refractory gastroparesis. Determining the appropriate extent of the pyloromyotomy continues to present a challenge as there are no standardized tools for measuring changes in pyloric distensibility during the procedure. The objective of this study was to evaluate the utility of using impedance planimetry with endoscopic functional luminal imaging probe (FLIP) to measure changes in pyloric distensibility after POP, and to compare these changes with improvement in symptoms and objective gastric emptying. METHODS: Patients with medically refractory gastroparesis underwent POP with FLIP measurements of the pylorus (EndoFLIP®, Medtronic, Fridley MN). FLIP measurements, as well as changes in symptoms measured by the validated gastroparesis cardinal symptom index (GCSI) and scintigraphic gastric emptying studies (GES), were evaluated before and after POP. RESULTS: A total of 14 patients underwent measurement with FLIP during POP, 12 of whom had pre- and post-POP measurements. Mean pyloric diameter increased by 1.4 mm, from 13.9 mm to 15.3 mm (p = 0.0012). Mean distensibility index increased from 6.2 mm2/mmHg to 9.1 mm2/mmHg (p = 0.0074). Successful division of the pylorus was achieved in 100% of patients with a mean operative time of 36 min and no perioperative complications. The mean length of stay was 0.7 days (0-3 days). Post-POP mean GCSI score improved from 2.97 to 2.28 at a mean follow-up time of 27 days (p < 0.001). Objective improvement in gastric emptying was observed in 80% of patients with scintigraphic GES, with mean four-hour retention decreasing from 46.3% to 32.4% (p < 0.007). CONCLUSIONS: FLIP is a safe and feasible tool to provide objective measurements during POP. Larger cohorts with longer follow-up are required to determine if measured improvements in pyloric diameter and distensibility are predictive of sustained improvements in GCSI and GES.

Pathological and oncological outcomes of pylorus-preserving versus conventional distal gastrectomy in early gastric cancer: a systematic review and meta-analysis.

BACKGROUND: Pylorus-preserving gastrectomy (PPG) is a function-preserving surgery for the treatment of early gastric cancer (EGC) in the middle third of the stomach. According to the literature reports, PPG decreases the incidence of dumping syndrome, bile reflux, gallstone formation, and nutritional deficit compared with conventional distal gastrectomy (CDG). However, the debates about PPG have been dominated by the incomplete lymphadenectomy and oncological safety. We carried out a systematic review and meta-analysis to evaluate the pathological and oncological outcomes of PPG. METHODS: The protocol was registered in PROSPERO under number CRD42022304677. Databases including PubMed, Embase, Web of Science, and the Cochrane Register of Controlled Trials were searched before February 21, 2022. The outcomes included the pooled odds ratios (ORs) for dichotomous variables and weighted mean differences (WMDs) for continuous variables. For all outcomes, 95% confidence intervals (CIs) were calculated. Meta-analysis was performed using STATA software (Stata 14, Stata Corporation, Texas) and Review Manager 5.4. RESULTS: A total of 4500 patients from 16 studies were included. Compared with the CDG group, the PPG group had fewer lymph nodes harvested (WMD= -3.09; 95% CI -4.75 to -1.43; P < 0.001). Differences in the number of resected lymph nodes were observed at stations No. 5, No. 6, No. 9, and No. 11p. There were no differences in lymph node metastasis at each station. Shorter proximal resection margins (WMD = -0.554; 95% CI -0.999 to -0.108; P = 0.015) and distal resection margins (WMD = -1.569; 95% CI -3.132 to -0.007; P = 0.049) were observed in the PPG group. There were no significant differences in pathological T1a stage (OR = 0.99; 95% CI 0.80 to 1.23; P = 0.88), T1b stage (OR = 1.01; 95% CI 0.81 to 1.26; P = 0.88), N0 stage (OR = 0.97; 95% CI 0.63 to 1.48; P = 0.88), tumor size (WMD = -0.10; 95% CI -0.25 to 0.05; P = 0.187), differentiated carcinoma (OR = 1.04; 95% CI 0.74 to 1.47; P = 0.812) or signet ring cell carcinoma (OR = 1.22; 95% CI 0.90 to 1.64; P = 0.198). No significant differences were observed between the groups in terms of overall survival (HR = 0.63; 95% CI 0.24 to 1.67; P = 0.852) or recurrence-free survival (HR = 0.29; 95% CI 0.03 to 2.67; P = 0.900). CONCLUSIONS: The meta-analysis of existing evidence demonstrated that the survival outcomes of PPG may be comparable to those of CDG. However, fewer lymph nodes at stations in No. 5, No. 6, No. 9, and No. 11p were harvested with PPG. We also found shorter proximal resection margins and distal resection margins for PPG, meaning more remnant stomachs would be preserved in PPG.

The PrEDICT-DGE score as a simple preoperative screening tool identifies patients at increased risk for delayed gastric emptying after pancreaticoduodenectomy.

BACKGROUND: Morbidity after Pancreaticoduodenectomy (PD) has remained unchanged over the past decade. Delayed Gastric Emptying (DGE) is a major contributor with significant impact on healthcare-costs, quality of life and, for malignancies, even survival. We sought to develop a scoring system to aid in easy preoperative identification of patients at risk for DGE. METHODS: The ACS-NSQIP dataset from 2014 to 2018 was queried for patients undergoing PD with Whipple or pylorus preserving reconstruction. 15,154 patients were analyzed using multivariable logistic regression to identify risk factors for DGE, which were incorporated into a prediction model. Subgroup analysis of patients without SSI or fistula (primary DGE) was performed. RESULTS: We identified 9 factors independently associated with DGE to compile the PrEDICT-DGE score: Procedures (Concurrent adhesiolysis, feeding jejunostomy, vascular reconstruction with vein graft), Elderly (Age>70), Ductal stent (Lack of biliary stent), Invagination (Pancreatic reconstruction technique), COPD, Tobacco use, Disease, systemic (ASA>2), Gender (Male) and Erythrocytes (preoperative RBC-transfusion). PrEDICT-DGE scoring strongly correlated with actual DGE rates (R2 = 0.95) and predicted patients at low, intermediate, and high risk. Subgroup analysis of patients with primary DGE, retained all predictive factors, except for age>70 (p = 0.07) and ASA(p = 0.30). CONCLUSION: PrEDICT-DGE scoring accurately identifies patients at high risk for DGE and can help guide perioperative management.

Is duodeno-jejunal bypass liner superior to pylorus preserving bariatric surgery in terms of complications and efficacy?

PURPOSE: Based on recent scientific evidence, bariatric surgery is more effective in the management of morbid obesity and related comorbidities than conservative therapy. Pylorus preserving surgical procedures (PPBS) such as laparoscopic single-anastomosis duodeno-jejunal or duodeno-ileal bypass with sleeve gastrectomy are modified duodenal switch (DS) surgical techniques. The duodeno-jejunal bypass liner (DJBL) is a novel surgical method in the inventory of metabolism focused manual interventions that excludes duodeno-jejunal mucosa from digestion, mimicking DS procedures without the risk of surgical intervention. The aim of this article is to summarize and compare differences between safety-related features and weight loss outcomes of DJBL and PPBS. METHODS: A literature search was conducted in the PubMed database. Records of DJBL-related adverse events (AEs), occurrence of PPBS-related complications and reintervention rates were collected. Mean weight, mean body mass index (BMI), percent of excess of weight loss (EWL%), percent of total weight loss (TWL%) and BMI value alterations were recorded for weight loss outcomes. RESULTS: A total of 11 publications on DJBL and 6 publications on PPBS were included, involving 800 and 1462 patients, respectively. The baseline characteristics of the patients were matched. Comparison of DJBL-related AEs and PPBS-related severe complications showed an almost equal risk (risk difference (RD): -0.03 and confidence interval (CI): -0.27 to 0.21), despite higher rates among patients having received endoscopic treatment. Overall AE and complication rates classified by Clavien-Dindo showed that PPBS was superior to DJBL due to an excess risk level of 25% (RD: 0.25, CI: 0.01-0.49). Reintervention rates were more favourable in the PPBS group, without significant differences in risk (RD: -0.03, CI: -0.27 to 0.20). However, PPBS seemed more efficient regarding weight loss outcomes at 1-year follow-up according to raw data, while meta-analysis did not reveal any significant difference (odds ratio (OR): 1.08, CI: 0.74-1.59 for BMI changes). CONCLUSION: Only limited conclusions can be made based on our findings. PPBS was superior to DJBL with regard to safety outcomes (GRADE IIB), which failed to support the authors' hypothesis. Surgical procedures showed lower complication rates than the incidence of DJBL-related AEs, although it should be emphasized that the low number of PPBS-related mild to moderate complications reported could be the result of incomplete data recording from the analysed publications. Weight loss outcomes favoured bariatric surgery (GRADE IIB). As the DJBL is implanted into the upper gastrointestinal tract for 6 to 12 months, it seems a promising additional method in the inventory of metabolic interventions.

Techniques and devices for the endoscopic treatment of gastroparesis (with video).

BACKGROUND AND AIMS: Gastroparesis is a symptomatic chronic disorder of the stomach characterized by delayed gastric emptying in the absence of mechanical obstruction. Several endoscopic treatment modalities have been described that aim to improve gastric emptying and/or symptoms associated with gastroparesis refractory to dietary and pharmacologic management. METHODS: In this report we review devices and techniques for endoscopic treatment of gastroparesis, the evidence regarding their efficacy and safety, and the financial considerations for their use. RESULTS: Endoscopic modalities for treatment of gastroparesis can be broadly categorized into pyloric, nonpyloric, and nutritional therapies. Pyloric therapies such as botulinum toxin injection, stent placement, pyloroplasty, and pyloromyotomy specifically focus on pylorospasm as a therapeutic target. These interventions aim to reduce the pressure gradient across the pyloric sphincter, with a resultant improvement in gastric emptying. Nonpyloric therapies, such as venting gastrostomy and gastric electrical stimulation, are intended to improve symptoms. Nutritional therapies, such as feeding tube placement, aim to provide nutritional support. CONCLUSIONS: Several endoscopic interventions have shown utility in improving the quality of life and symptoms of select patients with refractory gastroparesis. Methods to identify which patients are best suited for a specific treatment are not well established. Endoscopic pyloromyotomy is a relatively recent development that may prove to be the preferred pyloric-directed intervention, although additional and longer-term outcomes are needed.

Per oral pyloromyotomy utilizing a lesser curvature approach: how we do it.

BACKGROUND: The treatment of gastroparesis refractory to medical therapy has evolved to include purely endoscopic techniques. Per oral pyloromyotomy (POP) has evolved from traditional laparoscopic or open pyloroplasty to become a safe and effective minimally invasive option for patients with gastroparesis. As compared to laparoscopic pyloroplasty (LP), POP produces similar improvements in gastric emptying and symptom mitigation, while having shorter lengths of stay. There are slight variations in technique that vary by institution. Described here is a technique utilizing a lesser curve approach, with a mucosotomy closure using clips in an effort to maximize efficiency of the procedure. METHODS: Preoperative workup includes a scintigraphic gastric emptying study or a wireless motility capsule study, and the Gastroparesis Cardinal Symptom Index (GCSI). After an upper endoscopy, the procedure begins with injection into the submucosal space with methylene blue in saline on the lesser curve, 3-5 cm proximal to the pylorus. A 1.5 cm incision is then made with the ERBE hybrid knife. A submucosal tunnel is created past the distal end of the pylorus, and the muscle is hooked, and divided with the hybrid knife. The mucosotomy is closed with clips (Boston Scientific Resolution 360, Boston, MA) after the completion of the myotomy. Post-operatively, patients are discharged home after an overnight stay with a proton pump inhibitor, sucralfate, and a full liquid diet for 2 weeks. CONCLUSIONS: A lesser curve approach with mucosotomy closure using clips is a safe, effective, and efficient modality for performing POP. As more centers adopt POP as a tool for gastroparesis management, the lesser curve method limits the length of the submucosal tunnel needed, and allows for wide adoption of the technique.

Clinical efficacy of gastric per-oral endoscopic myotomy (G-POEM) in the treatment of refractory gastroparesis and predictors of outcomes: a systematic review and meta-analysis using surgical pyloroplasty as a comparator group.

BACKGROUND AND AIMS: Gastric peroral endoscopic myotomy (G-POEM) is a novel minimally invasive technique in endosurgery. Data is limited as to its efficacy, safety, and predictive factors. We conducted this meta-analysis to evaluate the clinical outcomes of G-POEM and used the outcomes of surgical pyloroplasty as a comparator group in the treatment of refractory gastroparesis. METHODS: We searched multiple databases from inception through March 2019 to identify studies that reported on G-POEM and pyloroplasty in gastroparesis. Our primary outcome was to analyze and compare the pooled rates of clinical success, in terms of Gastroparesis Cardinal Symptom Index (GCSI) score and 4-h gastric emptying study (GES) results, with G-POEM and pyloroplasty. RESULTS: Three hundred and thirty-two and 375 patients underwent G-POEM (11 studies) and surgical pyloroplasty (seven studies), respectively. The pooled rate of clinical success, based on the GCSI score, with G-POEM was 75.8% (95% CI 68.1-82.1, I2 = 50) and with surgical pyloroplasty was 77.3% (95% CI 66.4-85.4, I2 = 0), with no significance, p = 0.81. The pooled rate of clinical success, based on the 4-hour GES results, with G-POEM was 85.1% (95% CI 68.9-93.7, I2 = 74) and with surgical pyloroplasty was 84% (95% CI 64.4-93.8, I2 = 81), with no significance, p = 0.91. The overall adverse events were comparable. Based on meta-regression analysis, idiopathic gastroparesis, prior treatment with botulinum toxin and gastric stimulator seemed to predict clinical success with G-POEM. CONCLUSION: G-POEM demonstrates clinical success in treating refractory gastroparesis. Idiopathic gastroparesis, prior treatment with botulinum injections and gastric stimulator appear to have positive predictive effects on the 4-h GES results after G-POEM. Outcomes seem comparable to surgical pyloroplasty.

A comparison between pylorus-preserving and distal gastrectomy in surgical safety and functional benefit with gastric cancer: a systematic review and meta-analysis.

BACKGROUND: Due to better functional outcomes, pylorus-preserving gastrectomy (PPG) has been widely applied for early gastric cancer (EGC) patients as an alternative to distal gastrectomy (DG). However, controversies still persist regarding the surgical efficacy and oncological safety of PPG. METHODS: Original studies comparing PPG and DG for EGC were searched in PubMed, Embase, and the Cochrane Register of Controlled Trials up to December 2019. The weight mean difference, standardized mean difference, or odds risk was used to calculate the short-term and long-term outcomes between the two groups. RESULTS: Twenty-one comparative studies comprising 4871 patients (1955 in the PPG group and 2916 in the DG group) were enrolled in this systematic review and meta-analysis. PPG showed longer hospital day, decreased harvested lymph nodes, and more delayed gastric emptying. However, PPG had the benefits of lower incidence of anastomosis leakage, early dumping syndrome, gastritis and bile reflux, and better recovery of total protein, albumin, hemoglobin, and weight. No difference was found in operative time, blood loss, and overall complications. Moreover, the long-term survival and recurrence rate were similar in two groups. CONCLUSION: Owing to the non-inferiority of surgery and oncology outcomes and the superiority of function outcomes in PPG, we revealed that PPG can be clinically applicable instead of DG in EGC. However, more high-quality comparative studies and randomized clinical trials would be required for further confirmation.

Therapeutic effect of a temporary transpyloric stent in refractory post-surgical gastroparesis: a case report.

BACKGROUND: Gastroparesis is a syndrome characterized by delayed gastric emptying with associated symptoms. It was reported that the symptoms of diabetic gastroparesis had been greatly improved by transpyloric stent placement. However, the use of stents in benign conditions is considered to be contraindicated because of the increasing risk of complications, such as stent migration, reflux, perforation, bleeding, and, most importantly, new strictures caused by stent-induced tissue hyperplasia. While temporary placement of a self-expanding metallic stent (SEMC) can drastically reduce the risk of complications, few reports are available on the treatment of refractory PSG by temporary transpyloric stent. Does it have a long-term clinical effect after the stent being retrieved? CASE PRESENTATION: After accepting partial resection of the lesser curvature in another hospital, a patient developed refractory gastroparesis. The symptoms hadn't been improved after long-term drug therapy and balloon dilation therapy. Four months after surgery, a fully covered SEMC was placed by endoscopy in our hospital. Gastroparesis had been greatly improved. Two weeks later, the transpyloric stent was retrieved and the patient didn't show recurrent symptoms. Follow-ups were arranged at 3 months, 6 months and 1 year respectively, and there was no evidence of recurrence was found. CONCLUSIONS: This case indicates that temporary transpyloric SEMC is a safe, effective and less invasive alternative for post-surgical gastroparesis patients.

Pancreaticojejunostomy with or without reinforcement after pancreaticoduodenectomy: surgical technique of ligamentum teres hepatis wrap around pancreaticojejunostomy.

In a previous issue of the Journal, Zhong et al. reported a retrospective study that compared the perioperative outcomes of the mesh-reinforced pancreaticojejunostomy with conventional pancreaticojejunostomy. They concluded that mesh-reinforced pancreaticojejunostomy was a safe and effective technique, as it provided a safe anchor site for suture, thus reducing the risk of pancreatic leakage. Considering these encouraging results, we present a further simple technique using ligamentum teres hepatis wrap around pancreatojejunostomy for prevention of postoperative pancreatic fistula after pancreaticoduodenectomy.

Management of Pylorus During Esophagectomy. To Drain or Not to Drain?

Dear Editor, delayed gastric emptying due to bilateral vagotomy after esophagectomy, has been associated with increased aspiration rates, prolonged hospital stay and impaired quality of life. A pyloric drainage procedure in an effort to reduce its incidence, most commonly a pyloroplasty, represented for years a standard part of distal esophagectomy. This trend has been reevaluated nowadays and the question that still remains open is whether we should further keep on draining pylorus during esophagectomy or not. Surgical pyloric drainage (pyloroplasty/pyloromyotomy), although effective, is directly related to respectable complication rates, such as leakage, bile reflux, dumping sydrome or even postoperative stenosis, with potential fatal outcome. There are several proposed techniques for performing a pyloroplasty nowadays. Heineke- Mikulicz variant is the most widely practiced pyloroplasty (in contrary to Finney or Jaboulay alternatives) and is ideally performed via a 5-cm-long fullthickness antroduodenal longitudinal incision. Pyloroplasty can also be safely performed with a circular or linear stapler, while laparoscopic assisted trans-oral stapled pyloroplasty is also feasible (1).

Gastric per-oral endoscopic myotomy for refractory gastroparesis: results from the first multicenter study on endoscopic pyloromyotomy (with video).

BACKGROUND AND AIMS: Gastric per-oral endoscopic myotomy (G-POEM) recently has been reported as minimally invasive therapy for gastroparesis. The aims of this study were to report on the first multicenter experience with G-POEM and to assess the efficacy and safety of this novel procedure for patients with gastroparesis with symptoms refractory to medical therapy. METHODS: All patients with gastroparesis who underwent endoscopic pyloromyotomy (G-POEM) at 5 medical centers were included. Procedures were performed following the same principles as esophageal POEM. Clinical response was defined as improvement in gastroparetic symptoms with absence of recurrent hospitalization. Adverse events were graded according to the American Society for Gastrointestinal Endoscopy lexicon. RESULTS: A total of 30 patients with refractory gastroparesis (11 diabetic, 12 postsurgical, 7 idiopathic) underwent G-POEM. Previous therapies included Botox injection in 12, transpyloric stenting in 3, and PEG with jejunal extension (PEGJ) in 1. Nausea/vomiting were the predominant symptoms in 25 patients. Weight loss was present in 27 patients with an average of 10% loss of body weight. G-POEM was completed successfully in all 30 (100%) patients with a mean procedure time of 72 minutes (range, 35-223 min). The mean myotomy length was 2.6 ± 2.3 cm. The mean length of hospital stay was 3.3 days (range, 1-12 days). Two adverse events occurred in 2 (6.7%) patients, including 1 capnoperitoneum and 1 prepyloric ulcer, rated as mild and severe, respectively. Clinical response was observed in 26 (86%) patients during a median follow-up of 5.5 months. Four patients (2 diabetic, 1 postsurgical, 1 idiopathic cause) did not respond to G-POEM. Repeat gastric emptying scan was obtained in 17 patients, normalized in 8 (47%), and improved in 6 (35%) patients. CONCLUSION: G-POEM is a technically feasible procedure. This small non-randomized study suggests the effectiveness of G-POEM for the treatment of patients with gastroparesis refractory to medical therapy. It concomitantly results in normalization of GES in a significant proportion of treated patients.