First European human gastric peroral endoscopic myotomy, for treatment of refractory gastroparesis

Gastroparesis is a chronic functional syndrome that affects 4 % of the population [1] with an impact on quality of life. The etiologies include diabetic, post gastric surgery, and idiopathic forms [2]. Diagnosis is based on symptoms related to gastric emptying and on endoscopy and scintigraphy. The therapeutic options, including drugs (metoclopramide, erythrocin), surgery (pyloroplasty, gastric electrical stimulation), or endoscopy (botulinum toxin injection) remain insufficiently effective [3] [4] [5] [6] [7]. However, the physiopathology of gastroparesis implies stomach motility disorders as well as pyloric hypertonicity [8], and a US team has recently described the first case of gastric peroral endoscopic myotomy (G-POEM) by submucosal tunnel creation, and has reported a good outcome [9] [10].

We have therefore carried out G-POEM in a 51-year-old diabetic woman who suffered from disabling and refractory clinical gastroparesis; this was confirmed with by gastric emptying scintigraphy that showed an increased gastric emptying half-time. The option of gastric electrical stimulation was not available. Consequently, G-POEM was proposed to the patient, with clear information being given and written consent obtained.

The procedure was done with a wide-channel gastroscope (3.8 mm; Pentax, Tokyo, Japan) and using carbon dioxide insufflation after orotracheal intubation. The procedural steps were: (i) submucosal injection in the antrum, 5 cm upstream from the pylorus; (ii) mucosal incision in the posterior part of the antrum, using a DualKnife (Olympus, Japan); (iii) tunnel creation up to the pylorus ([Fig. 1] and [Fig. 2]); and (iv) pyloromyotomy of length 3 cm, using a Triangle Tip knife (Olympus, Tokyo, Japan) ([Fig. 3]). The mucosal defect was closed using endoclips (Instinct; Cook Medical, Bloomington, Indiana, USA) ([Fig. 4]). The procedure took 80 minutes ([Video 1]), with no intraoperative or postoperative complications. The patient resumed oral intake on postoperative day 1 and was discharged after postoperative day 5.

Fig. 1 Gastric peroral endoscopic myotomy (G-POEM) for refractory gastroparesis in a patient with diabetes: creation of the submucosal tunnel by endoscopic dissection.

Fig. 2 The pyloric muscle seen endoscopically from inside the submucosal tunnel.

Fig. 3 Appearance of the pyloric muscle after myotomy with a Triangle Tip knife.

Fig. 4 Endoscopic monitoring of the closure of the mucosal defect that had been performed using endoclips.

Gastric peroral endoscopic myotomy (G-POEM) for refractory gastroparesis in a patient with diabetes.

The patient was followed up clinically after 1 month, and reported significant improvement in her symptoms. This improvement persisted after 3 months and a gastric scintigraphy showed normalization of the gastric emptying half-time.

In conclusion, this first European procedure has shown that G-POEM for gastroparesis is feasible and seems effective. This needs to be confirmed in a prospective study.

Endoscopy_UCTN_Code_TTT_1AO_2AN

 

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Competing interests: None

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