Gastroesophageal reflux following per-oral endoscopic myotomy: Can we improve outcomes?

This editorial is an analysis the review article by Nabi et al recently published in this journal. Achalasia Cardia is a disease whose pathophysiology is still unclear. It is known that there is inflammation of unknown aetiology leading to loss of ganglion cells in the muscularis propria. The end result is lower oesophageal sphincter spasm, loss of receptive relaxation, decreased oesophageal peristalsis, all leading on to varying degrees of dysphagia. The treatment of this condition is palliative in nature, performed by myotomy of the lower oesophagus either surgically or endoscopically. Gastroesophageal reflux disease (GERD) has been associated with the myotomy performed, particularly with the Peroral Endoscopic Myotomy (POEM) procedure. Nabi et al have provided an excellent overview of the latest developments in predicting, preventing, evaluating, and managing GERD subsequent to POEM. Based on this theme, this review article explores the concept of using histology of the oesophageal muscle layer, to grade the disease and thereby help tailoring the length/type of myotomy performed during the POEM procedure. In the future, will a histology based algorithm available preoperatively, help modify the POEM procedure, thereby decreasing the incidence of GERD associated with POEM?

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.

Effectiveness of two-dimensional shear-wave sonoelastography in the diagnosis and follow-up of infantile hypertrophic pyloric stenosis.

INTRODUCTION: We sought to determine the effectiveness and utility of two-dimensional shear-wave sonoelastography (2D-SW-SE) in the diagnosis and postoperative follow-up of infantile hypertrophic pyloric stenosis (IHPS). MATERIALS AND METHODS: Twenty-three infants were included in the study, 13 in the IHPS group and 10 in the control group (CG). Preoperative B-mode ultrasonography measurements (longitudinal length and single-wall thickness of the pylorus) and 2D-SW-SE measurements (pylorus tissue stiffness and shear-wave propagation speed) were compared between the groups. The infants with IHPS then underwent Ramstedt pyloromyotomy and were invited for follow-ups on the tenth day and the first, third, and sixth months postoperatively. Measurements taken at the follow-ups were compared with the preoperative values. RESULTS: No differences were found between the groups regarding age, gender, body weight, or week of birth. The pyloric lengths in the IHPS group were longer than in the CG (p < 0.001), and the single-wall thicknesses were thicker (p < 0.001). The pylorus in the IHPS group was four times stiffer than in the CG (27.4 kPa versus 7.66 kPa), and the shear-wave propagation speed in the tissue was higher (1.34 m/s versus 2.69 m/s; p < 0.001). Both values decreased over time in the IHPS group and were normal by the third postoperative month. CONCLUSIONS: 2D-SW-SE can be used as an assistive imaging tool alongside B-mode ultrasound for diagnosing IHPS. It can also be used to identify inadequate surgery by detecting whether the pyloric tissue has softened at follow-up.

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.

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.

Role of gastric peroral endoscopic myotomy (GPOEM) in chronic gastroparesis management after pancreas transplantation.

Gastroparesis is a common complaint among patients with diabetes. Symptoms tend to improve following successful pancreas transplantation (PTx), but persist despite euglycemia in a subset of patients. We aimed to assess the benefit of gastric peroral endoscopic myotomy (G-POEM) in persistent gastroparesis following PTx. This was a single center retrospective review of all patients who underwent G-POEM for persistent gastroparesis following PTx. Patient demographics, pre and post procedure perception of symptom severity according to the patient assessment of upper gastrointestinal symptoms severity index (PAGI-SYM), gastroparesis cardinal symptom index (GCSI) score, and 36-item short form survey (SF36) score along with gastric emptying scintigraphy (GES) were analyzed. Seven PTx recipients underwent G-POEM for persistent gastroparesis symptoms. The majority were female. All reported nausea/vomiting, abdominal pain, bloating, and post prandial fullness prior to G-POEM. The post procedure survey scores improved in all patients although this was not significant. The improvement in gastric emptying on GES was statistically significant. G-POEM is a relatively new treatment option for gastroparesis. While it requires specialized proceduralist and training, we have documented improvement in the management of symptoms. With increasing experience, we anticipate more significant benefit in post PTx patients with persistent symptoms of gastroparesis undergoing G-POEM.

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.

Subtotal pyloric obstruction by atypical hypertrophic pyloric muscle in a newborn.

This is a case of a neonate with suspected duodenal atresia on prenatal imaging. However, distal bowel gas was identified postnatally on regular X-rays with a possible pyloric obstructing mass visualised on ultasound. No contrast was visualised passing through the stomach on fluoroscopic studies. Operative evaluation revealed an atypical asymmetric hypertrophic pylorus with exophytic lesions of ectopic glandular tissue. Longitudinal open pyloromyotomy was performed which relieved the gastric obstruction resulting in symptomatic relief without any anatomy altering procedure required.

G-POEM for gastroparesis: past, present and future.

PURPOSE OF REVIEW: Gastroparesis is a chronic debilitating condition with rising incidence and healthcare burden. As abdominal surgeries, diabetes, viral infections and autoimmune diseases become more prevalent, gastroparesis will continue to upsurge. Conservative treatment options for gastroparesis are limited by their side effects and short-term efficacy. Gastric endoscopic pyloromyotomy (G-POEM) is a novel incisionless endosurgical technique with excellent long-term outcomes. This review is in time, as the demand for G-POEM will continue to escalate. RECENT FINDINGS: This review encompasses the conservative and nonconservative treatment options for gastroparesis. G-POEM is a nonconservative treatment option, and the aim of this review is to discuss the variations in technique of G-POEM, short-term and long-term clinical efficacy of G-POEM and adverse events associated with it. SUMMARY: G-POEM has high technical and clinical success with minimal adverse events. G-POEM outcomes are similar or superior when compared with other treatment options for refractory gastroparesis. G-POEM is being widely adopted and will become the preferred treatment choice in patients with refractory gastroparesis.

The First Application of Intraumbilical Longitudinal Incision to Pyloromyotomy for Hypertrophic Pyloric Stenosis.

OBJECTIVE: There are several approaches to pyloromyotomy for the treatment of hypertrophic pyloric stenosis including open transumbilical pyloromyotomy and laparoscopic pyloromyotomy. Beginning in 2012, we adopted intraumbilical longitudinal incision as a new transumbilical approach for pyloromyotomy. We describe details of the operative technique and results of this new approach. METHODS: We reviewed records of patients undergoing transumbilical pyloromyotomy from 2005 to 2018. Perioperative outcomes were compared between intraumbilical longitudinal incision and supraumbilical incision, the latter of which is the conventional incision for transumbilical pyloromyotomy. RESULTS: Twenty-four patients underwent pyloromyotomy with intraumbilical longitudinal incision (intraumbilical group) and 28 patients with supraumbilical incision (supraumbilical group). The median operative time was longer in the intraumbilical group (58.0 vs. 43.5 min, p = 0.002). However, the time to full feeding did not differ significantly between the two groups, and the median postoperative stay was shorter in the intraumbilical group (3 vs. 5.5 days, p = 0.003). There was no difference in the rate of complications (4.2% vs. 7.1%, p = 1.0). Scars after intraumbilical longitudinal incision were localized inside the umbilicus. CONCLUSION: Pyloromyotomy can be performed through intraumbilical longitudinal incision as safely as supraumbilical incision and intraumbilical longitudinal incision may improve cosmetic results. This approach can be an alternative technique for pyloromyotomy.

Single-incision versus conventional laparoscopic pyloromyotomy for pediatric hypertrophic pyloric stenosis: a systematic review and meta-analysis.

PURPOSE: To assess the safety and efficacy of single-incision versus conventional laparoscopic pyloromyotomy in pediatrics, we conducted a systematic review and meta-analysis. METHODS: A literature search was conducted to identify studies that compared single-incision laparoscopic pyloromyotomy (SILP) and conventional laparoscopic pyloromyotomy (CLP) for infants with hypertrophic pyloric stenosis (HPS). Meta-analysis was used to pool and compare variables such as operative time, time to full feeding, length of hospital stay, mucosal perforation, inadequate pyloromyotomy, wound infection, incisional hernia and overall complications. RESULTS: Among the 490 infants with HPS in the seven studies, 205 received SILP and 285 received CLP. There was significant longer time to full feeding for SILP compared with CLP. However, pooling the results for SILP and CLP revealed no significant difference in operative time, length of hospital stay and postoperative complications. CONCLUSIONS: SILP is a safe, feasible and effective surgical procedure for infants with HPS when compared to CLP. SILP is equivalent to CLP in terms of operative time, length of hospital stay and postoperative complications. We conclude that LS should be considered an acceptable option for HPS.

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.

Evaluation of the learning curve for laparoscopic pyloromyotomy.

BACKGROUND: Laparoscopic pyloromyotomy is the preferred surgical management of hypertrophic pyloric stenosis at most centers. We aimed to analyze the learning curve for laparoscopic pyloromyotomy using the experience of five fellowship-trained pediatric surgeons. METHODS: A retrospective review of consecutive patients undergoing laparoscopic pyloromyotomy was performed. All cases were performed with general surgery residents. Cumulative sum (CUSUM) analysis for operating time was performed for up to the first 150 consecutive cases for individual surgeons. Outcomes were compared to identify different phases of the learning curve for operative competency. RESULTS: A total of 414 patients were included in the analysis as not all surgeons had reached 150 cases at time of analysis. The mean operating time was 29.2 min for all cases across the 5 surgeons. CUSUM analysis for mean operating time revealed three phases of learning: Learning Phase (cases 1-16), Plateau Phase (cases 17-87), and a Proficiency Phase (cases 88-150). The mean operating time during the three phases was 34.1, 29.0, and 28.3 min, respectively (P = 0.005). There were no differences in complications, reoperations, length of stay, or readmissions across the three phases. CONCLUSION: Three distinct phases of learning for laparoscopic pyloromyotomy were identified with no differences in outcomes across the phases. The operating time differed only for the Learning Phase, suggesting that some degree of proficiency occurs after 16 cases.

Questioning Prophylactic Antibiotic Use for Pyloromyotomy: Analysis of the Pediatric Health Information System Database.

BACKGROUND: Pyloromyotomy has a low rate of wound complications, yet antibiotic prophylaxis is still given. The Pediatric Health Information System (PHIS) database was queried to determine whether prophylactic antibiotics decreased wound complications. METHODS: Records for infants with pyloric stenosis between 2016 and 2021 were extracted from the PHIS database and analyzed for demographics, comorbid conditions, and complications within 30 days of pyloromyotomy. Logistic regression was used to evaluate the effect of antibiotic prophylaxis on complications. RESULTS: Among 14,247 infants who underwent pyloromyotomy, 29.5% had antibiotic prophylaxis. These patients were more likely to have been admitted to the NICU and have chronic conditions and prematurity (p < 0.01). Antibiotic utilization varied among hospitals from 2.3 to 58.5%. Complication rates among those who received antibiotics was 1.64% versus 1.62% for those who did not. The odds for developing complications in those who received prophylaxis compared to those who did not was 1.10, (0.73, 1.41, 95%, p = 0.93) suggesting there is no effect of antibiotics on complication rates. CONCLUSIONS: There was a wide variation among hospitals in the usage of prophylactic antibiotics for pyloromyotomy. There was no difference in complication rates whether or not patients received antibiotics. These results suggest antibiotic prophylaxis is unnecessary for pyloromyotomy. LEVEL OF EVIDENCE: III.

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.

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.