PYLORIC IMPEDANCE PLANIMETRY DURING ENDOSCOPIC PER-ORAL PYLOROMYOTOMY (POP) GUIDES MYOTOMY EXTENT.

BACKGROUND: Per-oral pyloromyotomy (POP), also known as gastric per-oral pyloromyotomy (G-POEM), is the first-line endoscopic intervention for medically refractory gastroparesis. We sought to assess the value of pyloric impedance planimetry using functional luminal imaging probe (FLIP) during POP. METHODS: Patients undergoing POP were retrospectively reviewed from October 2019-February 2024. FLIP measurements, symptoms measured by the gastroparesis cardinal symptom index (GCSI), and gastric emptying scintigraphy (GES) were evaluated before and after POP. RESULTS: Thirty-five patients (29 (82.9%) female, 51.3 (38.4, 60.9) years old, BMI 29.26 (25.46, 32.56kg/m2) underwent POP. Twenty-three patients had pre- and post-POP FLIP measurements. Median pyloric diameter increased from 14.4 (12, 16) to 16 (14.8, 18) mm (S=116.5, p<0.0001). Median distensibility index (DI) increased from 4.85 (3.38, 6) to 8.45 (5.25, 11) mm2/mmHg (S=112, p<0.0001). Management changed based on FLIP values for 5 patients (21.7%) prompting additional myotomy. At 18 (12.8, 47.8) days post-procedure, median GCSI score decreased from 3.33/5 (2.56, 4.12) preoperatively to 2/5 (1, 2.89) postoperatively (S=-193, p<0.001). At 136 (114, 277) day follow-, improvement in GCSI score persisted with a median score of 2.44/5 (1.44, 3.67) (S=-61, p=0.021). Median retention at 4hours on GES decreased from 29% (16.5, 52) to 19.5% (5.75, 35.3) at 97 (88, 130) days post-procedure (S=-108, p=0.0038). There was 75% improvement and 40% normalization of objective gastric emptying (n=26). Greater increase in diameter after pyloromyotomy correlated to a greater decrease in four-hour gastric retention (r=-0.4886, p=0.021). CONCLUSION: POP with FLIP resulted in clinical and radiographic improvement in patients with gastroparesis. FLIP measurements guided myotomy extent, changing management in 21.7% of patients and were correlated with gastric emptying, demonstrating its distinct utility in treatment of gastroparesis.

Efficacy of gastric per-oral endoscopic myotomy remains similar after failure of interventional techniques in refractory gastroparesis.

BACKGROUND AND AIMS: Gastric per-oral endoscopic myotomy (G-POEM) is a new therapeutic option for the treatment of refractory gastroparesis. However, the outcome of G-POEM after the failure of gastric electrical stimulation (GES) or other pylorus-targeting therapies has been poorly reported. METHODS: Data were collected from patients referred for G-POEM for refractory gastroparesis. The efficacy in patients with previous interventional techniques was compared to patients naïve to instrumental technique. The primary endpoint was the 6-month clinical success rate, defined as at least a 1-point decrease in the Gastroparesis Cardinal Symptom Index (GCSI). RESULTS: Among 48 patients referred for G-POEM, 32 patients had previous instrumental treatments (66%): 15 (31%) had GES, and 17 (35%) had pyloric endoscopic dilation or toxin injection. The technical success rate was 100%. At 6 months, clinical success was achieved in 25/48 patients (52%) and the GCSI decreased from 3.38 (2.94-3.95) to 2.25 (1.11-3.36) (p < 0.001). The 6-month success rate was similar in patients with or without previous instrumental treatment (50.0% vs 56.3%; p = 0.41). The complication rate was also similar in the two groups (6.3% vs 12.5%; p = 0.59), with only one severe adverse event. The only predictive factor for success at 6 months was a higher body mass index (OR = 1.14 [1.01-1.32]; p = 0.05). CONCLUSION: G-POEM is safe and remains effective after GES or previous pyloric treatment failure, with 50% efficacy at 6 months. The therapeutic strategy in refractory gastroparesis remains to be defined.

Intra-operative pyloric BOTOX injection versus pyloric surgery for prevention of delayed gastric emptying after esophagectomy.

BACKGROUND: Delayed gastric emptying (DGE) is a common complication after esophagectomy. BOTOX injections and pyloric surgeries (PS), including pyloroplasty (PP) and pyloromyotomy (PM), are performed intraoperatively as prophylaxis against DGE. This study compares the effects of pyloric BOTOX injection and PS for preventing DGE post-esophagectomy. METHODS: We retrospectively reviewed Moffitt's IRB-approved database of 1364 esophagectomies, identifying 475 patients receiving BOTOX or PS during esophageal resection. PS was further divided into PP and PM. Demographics, clinical characteristics, and postoperative outcomes were compared using Chi-Square, Fisher's exact test, Wilcoxon rank-sum, and ANOVA. Propensity-score matching was performed between BOTOX and PP cohorts. RESULTS: 238 patients received BOTOX, 108 received PP, and 129 received PM. Most BOTOX patients underwent fully minimally invasive robotic Ivor-Lewis esophagectomy (81.1% vs 1.7%) while most PS patients underwent hybrid open/Robotic Ivor-Lewis esophagectomy (95.7% vs 13.0%). Anastomotic leak (p = 0.57) and pneumonia (p = 0.75) were comparable between groups. However, PS experienced lower DGE rates (15.9% vs 9.3%; p = 0.04) while BOTOX patients had less postoperative weight loss (9.7 vs 11.45 kg; p = 0.02). After separating PP from PM, leak (p = 0.72) and pneumonia (p = 0.07) rates remained similar. However, PP patients had the lowest DGE incidence (1.9% vs 15.7% vs 15.9%; p = < 0.001) and the highest bile reflux rates (2.8% vs 0% vs 0.4%; p = 0.04). Between matched cohorts of 91 patients, PP had lower DGE rates (18.7% vs 1.1%; p = < 0.001) and less weight loss (9.8 vs 11.4 kg; p = < 0.001). Other complications were comparable (all p > 0.05). BOTOX was consistently associated with shorter LOS compared to PS (all p = < 0.001). CONCLUSION: PP demonstrates lower rates of DGE in unmatched and matched analyses. Compared to BOTOX, PS is linked to reduced DGE rates. While BOTOX is associated with more favorable LOS, this may be attributable to difference in operative approach. PP improves DGE rates after esophagectomy without improving other postoperative complications.

Initial experience and outcomes of per oral pyloromyotomy for the treatment of refractory gastroparesis.

BACKGROUND: Gastroparesis can be a debilitating disease process for which durable treatment options are lacking. While dietary changes and pharmacotherapy have some efficacy, symptoms frequently recur and some patients progress to needing supplemental enteral feeding access. Per oral pyloromyotomy (POP) has been shown to be a durable minimally invasive treatment option for refractory gastroparesis with a low side effect profile, and therefore has been performed at this institution for the past 6 years. METHODS: This was a retrospective case series of all patients who underwent a POP at a single institution over a 6-year period (2018-2023). Patient demographics, preoperative symptomatology and subsequent workup, postoperative complications, and symptom recurrence were collected and analyzed. RESULTS: There were 56 patients included in the study. There was a 1.8:1 female:male ratio. The average patient age was 56 years old (range 23-85). The average duration of symptoms was 1-3 years. Thirty-eight percent of patients had undergone previous endoscopic therapy for gastroparesis (pyloric botox injection or pyloric dilation) and 16% of patients underwent multiple endoscopic therapies. Twenty-nine percent of patients were on a medication for gastroparesis. Past surgery was the most common gastroparesis etiology for POP (50% of patients). Diabetes (23%) and idiopathic (19%) were the other most common gastroparesis etiologies for POP. Nausea was the most common symptom at first follow-up (30%) but these patients continued to improve with 14% of patients continuing to endorse nausea at 6 months. Twenty-seven percent of patients developed symptom recurrence. Forty percent of patients with symptom recurrence underwent a repeat endoscopic or surgical therapy. CONCLUSIONS: In this present study, POP leads to durable results in approximately 75% of patients with minimal complications. Furthermore, the majority of patients who do develop symptom recurrence do not require additional gastroparesis interventions.

Outcome of gastric electrical stimulator with and without pyloromyotomy for refractory gastroparesis.

BACKGROUND: Surgical treatments of refractory gastroparesis include pyloromyotomy and gastric electrical stimulator (GES). It is unclear if patients may benefit from a combined approach with concomitant GES and pyloromyotomy. METHODS: Retrospective cohort analysis of all patients with refractory gastroparesis treated with GES implantation with and without concomitant pyloromyotomy at Cleveland Clinic Florida from January 2003 to January 2023. Primary endpoint was efficacy (clinical response duration and success rate) and secondary endpoints included safety (postoperative morbidity) and length of stay. Success rate was defined as the absence of one of the following reinterventions during follow-up: Roux-en-Y gastric bypass (RYGB), pyloromyotomy, GES removal. RESULTS: During a period of 20 years, 134 patients were treated with GES implantation. Three patients with history of previous surgical pyloromyotomy or RYGB were excluded from the analysis. Median follow-up was 31 months (IQR 10, 72). Forty patients (30.5%) had GES with pyloromyotomy, whereas 91 (69.5%) did not have pyloromyotomy. Most of the patients had idiopathic (n = 68, 51.9%) or diabetic (n = 58, 43.3%) gastroparesis. Except for preoperative use of opioids (47.5 vs 14.3%; p < 0.001), patient's characteristics were similar in both groups. There were no significant differences between the two groups in terms of overall postoperative complications (17.5% vs 14.3%; p = 0.610), major postoperative complications (0% vs 2.2%; p = 1), and length of stay (2(IQR 1, 2) vs 2(IQR 1, 3) days; p = 0.068). At 5 years, success rate was higher in patients with than without pyloromyotomy however not statistically significant (82% versus 62%, p = 0.066). Especially patients with diabetic gastroparesis seemed to benefit from pyloromyotomy during GES (100% versus 67%, p = 0.053). In an adjusted Cox regression, GES implantation without pyloromyotomy was associated with a 2.66 times higher risk of treatment failure compared to GES implantation with pyloromyotomy (HR 2.66, 95% CI 1.03-6.94, p = 0.044). CONCLUSION: Pyloromyotomy during GES implantation for gastroparesis seems to be associated with a longer clinical response with similar postoperative morbidity and length of hospital stay than GES without pyloromyotomy. Patient with diabetic gastroparesis might benefit from a combination of GES implantation and pyloromyotomy.

Atropine as an Adjunct in the Management of Pediatric Patients With Hypertrophic Pyloric Stenosis: A Single Institution Experience and Review of the Literature.

Infantile hypertrophic pyloric stenosis (IHPS) is a condition whereby there is a thickening of the pyloric muscle, leading to obstruction of the gastric outflow. Typically present within three to five weeks of life, it presents as postprandial non-bilious projectile vomiting. Commonly, a pyloromyotomy is the gold standard to relieve the obstruction. However, in a subset of patients not amenable to undergo surgery or anesthesia, or for postoperative persistent or recurrent obstruction, atropine may offer an alternative treatment. A retrospective review was performed on pediatric patients with hypertrophic pyloric stenosis utilizing the electronic medical record. Data included were demographics, workup data, treatment, outcomes, and symptom resolution. Approval was obtained by the institutional review board of the host institution. Five pediatric patients, with an average age of 2.1 months, received atropine treatment for IHPS. The average time to reach full feeds since the initiation of atropine was approximately four days. Three of the five patients were successfully managed with IV atropine, which was then transitioned to oral atropine and tapered off as outpatients, leading to the resolution of symptoms. The remaining two patients were considered failures of medical management and subsequently required surgery. Atropine use as an alternative treatment for IHPS may be considered when patients are not able to undergo surgery or anesthesia or have recurrent or persistent obstructive symptoms postoperatively. In this limited study, atropine was found to be safe and effective. Randomized controlled studies may lend additional merit to this therapy in the future.

Do antro-duodenal manometry parameters predict clinical response after gastric peroral endoscopic pyloromyotomy in refractory gastroparesis?

BACKGROUND: Gastric peroral endoscopic pyloromyotomy (G-POEM) is a promising therapeutic modality for refractory gastroparesis (GP). However, as characteristics of suitable patients for G-POEM remain unclear, antro-duodenal manometry (ADM) has been suggested to provide objective parameters for patient selection. The aim of the present study was to identify ADM parameters as predictors for treatment response after G-POEM in refractory GP. METHODS: Refractory GP patients who underwent a G-POEM between 2017 and 2022 were included. The following ADM parameters were mainly scored: antral hypomotility, pylorospasm, and the presence of neuropathic enteric patterns. Treatment response was defined as a GCSI-score decrease of ≥1 point 12 months after G-POEM. Explorative analyses were performed on potential predictors of response using logistic regression analysis. KEY RESULTS: Sixty patients (52 women, mean age 52 ± 14 years.) with refractory GP (33 idiopathic, 16 diabetic, 11 postsurgical) were included. Clinical response data were available for 52 patients. In 8 out of 60 patients, it was not feasible to advance the catheter beyond the pylorus. Abnormal ADM was found in 46/60 patients (77%). Antral hypomotility and pylorospasm were found in respectively 33% and 12% of patients. At least one neuropathic enteric dysmotility pattern was found in 58% of patients. No differences were found when comparing baseline ADM parameters between clinical response groups at 12 months follow-up. Following explorative analyses, no ADM parameters were identified to predict clinical response 12 months after G-POEM. CONCLUSIONS AND INFERENCES: No ADM parameters were identified as predictors of clinical response after G-POEM in refractory GP patients. Additionally, a high percentage of abnormal ADM tracings was found, in particular with relation to enteric dysmotility, while only a low percentage of patients showed antral hypomotility or pylorospasm.

Comparison between umbilical and right upper transverse abdominal incisions for pyloromyotomy: a systematic review and meta-analysis.

The aim of this study was to compare the operative parameters and complication rates between the umbilical (UMB) and right upper quadrant (RUQ) skin incisions for Ramstedt's pyloromyotomy for the treatment of infantile hypertrophic pyloric stenosis (IHPS). PubMed, EMBASE, Web of Science and Scopus databases were systematically searched. The studies where any one of the main outcomes of interest, i.e., operative time, wound infection rate, mucosal perforation rate were reported were eligible for inclusion. The statistical analysis was performed using a random-effects model. The methodological quality of the studies was assessed utilizing the Newcastle-Ottawa Scale. Fifteen studies comprising 2964 infants were included. As compared to the UMB group, the RUQ group showed a significantly lower mean operative time (p = 0.0004), wound infection rate (p < 0.0001) and mucosal perforation rate (p = 0.02). Although UMB incision produces an almost undetectable scar, this approach results in significantly more complications. Therefore, the risks and benefits must be weighed and discussed with the caregivers in deciding the surgical approach in patients with IHPS. However, due to a poor methodological quality of nine out of fifteen studies, further studies need to be conducted for an optimal comparison between the two groups.

The Utility of Prophylactic Antibiotics for Laparoscopic Pyloromyotomy.

INTRODUCTION: Laparoscopic pyloromyotomy (LP) for the treatment of infantile hypertrophic pyloric stenosis (IHPS) is a clean case with low expected rates of postoperative surgical site infection (SSI). Previous studies have shown a low risk of SSI following LP but also large variations in the utilization of prophylactic antibiotics. The goal of this study was to review the use of preoperative antibiotics for LP and to compare this with SSI incidence. METHODS: We performed a retrospective single-center analysis of patients undergoing LP for infantile hypertrophic pyloric stenosis at a large quaternary children's hospital from January 2017 to June 2020. Subjects were <4 mo old. Exclusion criteria were those lost to follow-up within 30 d postoperatively and those who required open conversion intraoperatively. Statistical analysis was performed using Fisher's exact test, two-tailed independent t-tests, and descriptive statistics. RESULTS: Two-hundred twenty-seven patients were included, mean population age was 5.7 wk, and 81.1% were male. Preoperative antibiotics were administered in 39% of patients. Only 1.3% (n = 3) of all patients developed an SSI within 30 d of their operation. Analysis between patients who received preoperative antibiotics and those who did not revealed no difference in age (5.72 wk versus 5.72 wk, t (225) = 0.38, P = 0.70), sex (41% of males versus 32% of females, P = 0.39), length of stay (t(225) = -0.94, P = 0.35), or postoperative SSI (1.1% versus 1.4%, P > 0.999). Large variability was noted in antibiotic utilization by surgeon. CONCLUSIONS: In patients undergoing LP, there was no difference in SSI rates whether or not patients received preoperative antibiotics and, there is large variation in utilization. Measures are needed to decrease usage of prophylactic antibiotics before LP.

Case Report: Gas in the esophagus, stomach wall and portal vein with congenital hypertrophic pyloric stenosis.

Background: CHPS dramatically affects infant growth and development and can even cause aspiration resulting from esophageal reflux. There is potential danger. CHPS is common, while CHPS with gas in the stomach wall and portal vein is rare. Gas in the stomach wall and portal vein are often the key features of more serious disease. It can be easily mistaken as a serious disease when patients with CHPS have gas in the stomach wall and portal vein. Case presentation: A 56-day-old baby was hospitalized for aspiration pneumonia after vomiting without bile for 20 days. Compared with vomiting, which is the most common symptom, pneumonia tends to attract more attention. Because of pneumonia, a chest CT scan was performed and revealed massive gas accumulation in the walls of the esophagus, stomach, and portal vein. Therefore, NEC was considered first and was treated conservatively for one week. However, the vomiting continued, and CHPS was confirmed by ultrasound. The delay in CHPS diagnosis was due to insufficient recognition of the signs of gas accumulation. Because of inexperience and lack of knowledge about CHPS with gastrointestinal pneumatosis, physicians failed to make an early accurate diagnosis. Case 2 was a 29-day-old male who was admitted to the hospital with vomiting without bile. He was examined by ultrasound, which revealed gas in the stomach wall and portal vein after admission to the hospital. No peritonitis was found after a detailed and comprehensive physical examination. Emergency life-threatening diseases such as NEC were quickly ruled out. He received surgery as soon as possible and had an uneventful recovery with no complications. Conclusion: CHPS may present with gas in the gastric or esophageal wall and portal vein, which is not a contraindication to surgery.

Optimizing throughput of babies with infantile hypertrophic pyloric stenosis.

BACKGROUND: Definitive surgical care is often delayed in hypertrophic pyloric stenosis (HPS). Our aim is to evaluate the effect modifiable factors in preoperative HPS management have on efficiency of care. METHODS: A retrospective review of all patients undergoing pyloromyotomy for HPS at two US children's hospitals between 2008 and 2018 was performed. RESULTS: 406 patients were included in the study. The majority (310, 76 â€‹%) were adequately resuscitated and ready for surgery upon diagnosis in the ER. However, only 133 patients (43 â€‹%) had surgery on the day of admission. Patients diagnosed between 12pm and 6pm were more likely to have surgery the next day than those diagnosed before noon (67 â€‹% vs 33 â€‹%, p â€‹< â€‹.001), which correlated with a longer length of stay (32 vs 47 â€‹h, p â€‹< â€‹.001). CONCLUSION: The majority of patients presenting with HPS can safely undergo same day surgery. Delaying surgery due to an afternoon diagnosis is common, and leads to a modifiable increased total length of stay.

AGA Clinical Practice Update on Gastric Peroral Endoscopic Myotomy for Gastroparesis: Commentary.

DESCRIPTION: The purpose of this American Gastroenterological Association (AGA) Institute Clinical Practice Update (CPU) is to review the available evidence and provide expert advice regarding cognitive, procedural, and post-procedural aspects of performing gastric peroral endoscopic myotomy for the treatment of refractory gastroparesis. METHODS: This CPU was commissioned and approved by the AGA Institute Clinical Practice Updates Committee (CPUC) and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership and underwent internal peer review by the CPUC and external peer review through standard procedures of Gastroenterology. This expert commentary incorporates important as well as recently published studies in this field, and it reflects the experiences of the authors who are advanced endoscopists with expertise in treating patients by performing third-space endoscopy and gastric peroral endoscopic myotomy.

Nationwide trends of laparoscopic pyloromyotomy in patients with infantile hypertrophic pyloric stenosis in Germany: A slow path forward.

Since its introduction, laparoscopic pyloromyotomy (LP), has become increasingly popular in many countries. We have noticed an attenuated trend in Germany. The aim of this study was to analyse the distribution of open and LP in Germany. The national database of administrative claims data of the Institute for the Remuneration System in Hospitals (InEK) was analysed regarding numbers of patients with pyloromyotomy in the years 2019-2021. The German quality reports of the hospitals of 2019 and 2020 were analyzed regarding the number of procedures performed per hospital and pediatric surgical department. A total of 2050 patients underwent pyloromyotomy. The incidence of hypertrophic pylorus stenosis (HPS) was 699 and 657 patients in 2019 and 2021, respectively. Regarding age, 31.1% were admitted before 28 days of age. LP gradually increased from 216 patients (30.9%) in 2019 to 239 patients (36.4%) in 2021. Thirty-three laparoscopic operations (4.8%) were converted to an open approach. In 24 of all patients, there was an injury to the stomach, in 20 patients to the duodenum, needing repair with sutures. Analysis of the quality reports indicated that 44% of pediatric surgical departments performed LP. Although LP has became more prevalent in Germany recently, about two thirds of patients still undergo an open procedure.

2023 update on the clinical management of gastroparesis.

INTRODUCTION: Gastroparesis is characterized by symptoms suggesting gastric retention of food and objective evidence of delayed gastric emptying in the absence of a mechanical obstruction. Nausea, vomiting, early satiety, and postprandial fullness are the classic symptoms of gastroparesis. Gastroparesis is increasingly encountered by physicians. There are several recognized etiologies of gastroparesis, including diabetic, post-surgical, medication-induced, post-viral, and idiopathic. AREAS COVERED: A comprehensive literature review was conducted to identify studies discussing gastroparesis management. Dietary modifications, medication adjustments, glucose control, antiemetic agents, and prokinetic agents are all part of gastroparesis management. In this manuscript, we detail treatments evolving for gastroparesis, including nutritional, pharmaceutical, device, and recent advanced endoscopic and surgical therapies. This manuscript concludes with a speculative viewpoint on how the field will evolve in 5 years' time. EXPERT OPINION: Identification of the dominant symptoms (fullness, nausea, abdominal pain, and heartburn) helps to direct management efforts of the patients. Treatments for refractory (treatment resistant) symptoms may include gastric electric stimulation and intra-pyloric interventions like botulinum toxin and endoscopic pyloromyotomy. Understanding the pathophysiology of gastroparesis, relating pathophysiologic abnormalities to specific symptoms, new efficacious pharmacotherapies, and better understanding of the clinical predictors of response of therapies, are priorities for future research in the field of gastroparesis.

Gastric electrical stimulation versus per-oral pyloromyotomy for the treatment of nausea and vomiting associated with gastroparesis: An observational study of two cohorts.

BACKGROUND: Both gastric electrical stimulation (GES) and gastric-peroral endoscopic myotomy (G-POEM) can be offered to patients with gastroparesis and predominant nausea and vomiting. The study's aim was to compare GES and G-POEM efficacy on nausea and vomiting scores in patients with gastroparesis. METHODS: Two multicenter cohorts of patients with medically refractory gastroparesis with predominant nausea and vomiting (defined as a score >2 on nausea and vomiting subscale that varied from 0 to 4) were treated either with GES (n = 34) or G-POEM (n = 30) and were followed for 24 months (M). Clinical response was defined as a decrease of ≥1 point in nausea and vomiting subscale without premature exclusion due to switch from one to the other technique before M24. Changes in symptomatic scales and quality of life were also monitored. KEY RESULTS: Patients from both groups were comparable although the mean score of nausea and vomiting subscale was higher in GES (3.0) compared to G-POEM group (2.6; p = 0.01). At M24, clinical response was achieved in 21/34 (61.7%) patients with GES and in 21/30 (70.0%; p = 0.60) patients with G-POEM. Mean scores of nausea and vomiting subscale decreased at M24 in both GES (from 3.0 to 1.6; p < 0.001) and G-POEM (from 2.6 to 1.2; p < 0.001) groups, although there was no difference between groups (difference adjusted from baseline: -0.28 [-0.77; 0.19]; p = 0.24). Likewise, symptomatic and quality of life scores improved at M24 in both groups, without difference according to treatment group. CONCLUSIONS AND INFERENCES: At M24, we did not observe significant difference in efficacy of GES and G-POEM in medically refractory gastroparesis with predominant nausea and vomiting.

A Contemporary Review of Surgical Approach and Outcomes in Pediatric Hypertrophic Pyloric Stenosis.

INTRODUCTION: In order to define optimal resources and outcome standards for infant pyloromyotomy, we sought to perform a contemporary analysis of surgical approach (laparoscopic versus open) and outcomes. METHODS: The National Surgical Quality Improvement Project Pediatrics Participant Use File (NSQIP PUF) was queried from 2016 to 2020. Utilization of laparoscopy was trended over time. Complication rates and length of stay were compared by operative approach. RESULTS: 9752 pyloromyotomies were included in the analysis. The utilization of laparoscopy steadily increased over the study time period (66% to 79%) and was associated with a shorter operative time. On multivariate regression, the utilization of laparoscopy was associated with a lower risk of overall complications, length of stay, and superficial surgical site infections. Overall complication rates were lower than previously reported (2.02%). The most common complication was superficial infection (1.2%). CONCLUSIONS: In facilities reporting to pediatric National Quality Improvement Project, utilization of laparoscopy has steadily increased, and complication rates are lower than previously reported. Complication rates and length of stay were lower with the laparoscopic approach in this contemporary cohort. These results offer benchmarks for quality improvement initiatives. The laparoscopic approach should be standard in facilities performing this procedure.

Outcomes of Intraoperative Pyloric Drainage on Delayed Gastric Emptying Following Esophagectomy: A Systematic Review and Meta-analysis.

BACKGROUND: Intraoperative pyloric drainage in esophagectomy may reduce delayed gastric emptying (DGE) but is associated with risk of biliary reflux and other complications. Existing evidence is heterogenous. Hence, this meta-analysis aims to compare outcomes of intraoperative pyloric drainage versus no intervention in patients undergoing esophagectomy. METHODS: PubMed/MEDLINE, Embase, Web of Science, and the Cochrane were searched from inception up to July 2022. Exclusion criteria were lack of objective evidence (e.g., symptoms of nausea or vomiting) of DGE. The primary outcome was incidence of DGE. Secondary outcomes were incidence of pulmonary complications, bile reflux, anastomotic leak, operative time, and mortality. RESULTS: There were nine studies including 1164 patients (pyloric drainage n = 656, no intervention n = 508). Intraoperative pyloric drainage included pyloroplasty (n = 166 (25.3%)), pyloromyotomy (n = 214 (32.6%)), botulinum toxin injection (n = 168 (25.6%)), and pyloric dilatation (n = 108 (16.5%)). Pyloric drainage is associated with reduced DGE (odds ratio (OR): 0.54, 95% confidence interval (CI): 0.39-0.74, I2 = 50%). There was no significant difference in incidence of pulmonary complications (OR: 0.74, 95% CI: 0.51-1.08; I2 = 0%), biliary reflux (OR: 1.43, 95% CI: 0.80-2.54, I2 = 0%), anastomotic leak (OR: 0.79, 95% CI: 0.48-1.29; I2 = 0%), operative time (MD: + 22.16 min, 95% CI: - 13.27-57.59 min; I2 = 76%), and mortality (OR: 1.13, 95% CI: 0.48-2.64, I2 = 0%) between the pyloric drainage and no intervention groups. CONCLUSIONS: Pyloric drainage in esophagectomy reduces DGE but has similar post-operative outcomes. Further prospective studies should be carried out to compare various pyloric drainage techniques and its use in esophagectomy, especially minimally-invasive esophagectomy.

Targeting the pylorus in gastroparesis: From physiology to endoscopic pyloromyotomy.

BACKGROUND: The pylorus plays a key role in the control of gastric content outflow. Impairment of pyloric physiology has been observed in gastroparesis, particularly when associated with diabetes mellitus or opioid intake or after antireflux surgery. New tools have been developed to identify pyloric dysfunction in routine care, including functional luminal impedance planimetry (FLIP). As such, a new therapeutic strategy targeting the pylorus, namely endoscopic pyloromyotomy (G-POEM), has received increasing attention and emerged as a promising treatment for gastroparesis. PURPOSE: The present review details the involvement of the pyloric pathophysiology in gastroparesis, as well as clinical results of G-POEM according to the current literature.

Analysis of esthetic assessment scales in two surgical approaches for hypertrophic pyloric stenosis. / Evaluación de escalas de valoración estética en dos abordajes quirúrgicos para la estenosis hipertrófica de píloro.

INTRODUCTION: Hypertrophic pyloric stenosis (HPS) is a frequent pathology in neonates, with extramucosal pyloromyotomy being a healing surgery. It may be performed through a transverse subcostal incision (TSI) or a transumbilical incision (TUI). OBJECTIVE: To compare complications, operating times, hospital stay, and esthetic results between both techniques. MATERIALS AND METHODS: A retrospective, descriptive study of patients undergoing HPS surgery between January 2010 and January 2020 was carried out. Qualitative variables (sex and complications) were expressed as absolute frequency and percentage, whereas quantitative variables (age at surgery, operating time, hospital stay, and scar esthetic assessment scales: MVSS [Modified Vancouver Scar Scale] and P-SAS [Patient Scar Assessment Scale]) were expressed as median and interquartile range. RESULTS: 107 patients were analyzed: TSI (60.7%, n = 65) vs. TUI (39.3%, n = 42). Male patients: 89.2%, n = 58 vs. 83.3%, n = 35; age (days): 31 (24.5-39.5) vs. 34.5 (29.5-47.25); operating time (minutes): 41 (33.75-60) vs. 46 (38.5-60); and hospital stay (days): 2 (2-4) vs. 3 (2-3). Clavien-Dindo grade II complications were more frequent in the TUI Group (1.54%, n = 1 vs. 23.81%, n = 10; p <0.001), with most of them being wound infections. The opinion regarding the scar according to the MVSS scale was better in the TUI Group (1.5 [0-4] vs. 0 [0-2]; p = 0.022). No significant differences were found in the P-SAS scale (10 (6-18) vs. 6 (6-9); p = 0.060). CONCLUSIONS: TUI is preferred from an esthetic point of view, and even though surgical wound infections are more frequent, it is not associated with longer operating times, longer hospital stay, or severe complications.

INTRODUCCION: La estenosis hipertrófica de píloro (EHP) es una patología frecuente en neonatos donde la piloromiotomía extramucosa es una cirugía curativa. Puede realizarse a través de una incisión transversa subcostal (IT) o una incisión transumbilical (ITU). OBJETIVO: Comparar complicaciones, tiempo quirúrgico y de hospitalización y resultado estético entre ambas técnicas. MATERIAL Y METODOS: Estudio descriptivo retrospectivo en pacientes intervenidos de EHP entre enero 2010-2020. Variables cualitativas (sexo y complicaciones) expresadas mediante frecuencia absoluta y porcentaje; y cuantitativas (edad en cirugía, tiempo operatorio, días de hospitalización y escalas de estética de cicatrices: MVSS (Modified Vancouver Scar Scale) y P-SAS (Patient Scar Assessment Scale)) expresadas mediante mediana y rango intercuartílico. RESULTADOS: Se analizaron 107 pacientes: IT (60,7%, n = 65) vs. ITU (39,3%, n = 42): varones (89,2%, n = 58 vs. 83,3%, n = 35), días de vida (31 [24,5-39,5] vs. 34,5 [29,5-47,25]), tiempo quirúrgico (41 [33,75-60] vs. 46 [38,5-60] minutos) y días de hospitalización (2 [2-4] vs. 3 [2-3]). Las complicaciones Clavien-Dindo II fueron más frecuentes en el grupo ITU (1,54%, n = 1 vs. 23,81%, n = 10; p <0,001), siendo la mayoría infecciones de la herida. En el grupo ITU presentaban una mejor opinión sobre la cicatriz en la escala MVSS (1,5 [0-4] vs. 0 [0-2]; p = 0,022). La escala P-SAS no alcanzó diferencias significativas (10 [6-18] vs. 6 [6-9]; p = 0,060). CONCLUSIONES: La ITU es mejor aceptada a nivel estético y, aunque presenta más infecciones de herida quirúrgica, no precisa más tiempo quirúrgico o de ingreso, ni asocia complicaciones graves.