Modified per-oral plication of the neo-esophagus for refractory delayed gastric conduit emptying: a novel endoscopic approach

Delayed gastric conduit emptying (DGCE) affects 15–39% of patients after esophagectomy, increasing the risk of aspiration, pneumonia, and malnutrition [1]. “Sump” formation with chronic dilation often necessitates surgical intervention. Per-Oral Plication of the neo-Esophagus (POPE) is a novel endoscopic technique adapted from endoscopic sleeve gastroplasty (ESG) to remodel the neo-esophagus (and end-stage achalasia megaesophagus) and improve emptying [2], with 82.3% symptom improvement, although 23.5% requiring repeat intervention.

Studies of ESG have shown that 83.64% of sutures persist at 12 months, with 70.9% maintaining adequate tension [3]. Combining mucosal denudation techniques like argon plasma coagulation (APC) or endoscopic mucosal resection (EMR) may enhance submucosa to submucosa apposition leading to better suture retention and durability [4] [5].

We present a modified POPE by combining mucosal denudation techniques, to address sump-related retention and improve gastric emptying in a patient with refractory DGCE ([Video 1]).

Modified Per-Oral Plication of the (Neo)Esophagus (POPE) for refractory delayed gastric conduit emptying.Video 1

A 72-year-old woman with esophageal adenocarcinoma underwent partial esophagectomy with gastric conduit reconstruction in 2019. She developed early satiety, worsening heartburn when supine, and progressive oral intolerance, necessitating total parenteral nutrition. Imaging confirmed a neo-esophageal sump with significant retention. Dietary adjustments, prokinetics, and pyloric botulinum toxin injection failed, with worsening symptoms and bile reflux. A multidisciplinary team recommended POPE for sump remodeling.

Modified POPE was performed under general anesthesia in the supine position, using a suturing device without an overtube, combining with EMR and APC. Endoscopic and radiologic assessment confirmed improved conduit alignment and pyloric passage ([Fig. 1]). The patient was discharged after 48 hours without complications and tolerating diet. At a 4-month follow-up, endoscopy confirmed sustained remodeling with symptom improvement and no retention. In conclusion, modified POPE is a feasible, minimally invasive technique for refractory DGCE due to sump formation. Further studies are needed to evaluate long-term efficacy.

Fig. 1 Esophagogram previous to the intervention on the left; esophagogram after POPE on the right. Abbreviation: POPE, per-oral plication of the (neo)esophagus.

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Conflict of Interest

H. U. is proctor for ERBE Spain and Olympus Iberia. No other COI for the rest of authors.

Acknowledgement

Thank you to Dr. Clara Joaquin-Ortin from endocrinology department of Hospital Universitari Germans Trias I Pujol, and Drs. Eduard Espinet and Francisco Zozaya and Apollo and Boston Scientific Spain team for their support.

• References

• 1 Zhang R, Zhang L. Management of delayed gastric conduit emptying after esophagectomy. J Thorac Dis 2019; 11: 302-307
• 2 Crafts TD, Seidel H, Hedberg HM. et al. Efficacy and outcomes of per oral plication of the (neo)esophagus (POPE) for impaired emptying in achalasia and post-esophagectomy patients. Surg Endosc 2024; 38: 5239-5245
• 3 Espinet-Coll E, Díaz-Galán P, Nebreda-Durán J. et al. Persistence of Sutures and Gastric Reduction After Endoscopic Sleeve Gastroplasty: Radiological and Endoscopic Assessment. Obes Surg 2022; 32: 1969-1979
• 4 Jirapinyo P, De Moura DTH, Thompson CC. Endoscopic submucosal dissection with suturing for the treatment of weight regain after gastric bypass: outcomes and comparison with traditional transoral outlet reduction (with video). Gastrointest Endosc 2020; 91: 1282-1288
• 5 Thompson CC, Slattery J, Bundga ME. et al. Peroral endoscopic reduction of dilated gastrojejunal anastomosis after Roux-en-Y gastric bypass: a possible new option for patients with weight regain. Surg Endosc 2006; 20: 1744-1748

Publication History

Article published online:
06 May 2025