Per oral pyloromyotomy utilizing a lesser curvature approach: how we do it
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and Other Interventional Techniques
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Per oral pyloromyotomy utilizing a lesser curvature approach: how we do it Andrew M. Brown1 · Aurora D. Pryor1 · Salvatore Docimo Jr.1,2 Received: 21 April 2020 / Accepted: 7 July 2020 © Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract 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. Keywords Per oral pyloromyotomy · POP · G-POEM · Gastroparesis The management of symptomatic gastroparesis has evolved in the twenty-first century after the first reports in humans of per oral pyloromyotomy (POP) were successful [1, 2]. Symptomatic gastroparesis, characterized by bloating, abdominal pain, nausea, vomiting, and early satiety, has long been managed with medical therapies such as prokinetic Electronic supplementary material The online version of this article (https://doi.org/10.1007/s00464-020-07802-2) contains supplementary material, which is available to authorized users. * Salvatore Docimo Jr. [email protected] 1
Department of Surgery, Stony Brook University Hospital, Stony Brook, USA
Division of Bariatric, Foregut, and Advanced Gastrointestinal Surgery, Department of Surgery, Health Sciences Center, T19-053, Stony Brook Medicine, Stony Brook, NY 11794‑8191, USA
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