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PER-ORAL PYLOROMYOTOMY (POP) FOR MEDICALLY REFRACTORY POST-SURGICAL GASTROPARESIS
Andrew T. Strong*1,2, Joshua P. Landreneau1, Michael S. Cline3, Matthew Kroh4,2, John Rodriguez1,2, Jeffrey L. Ponsky1,2, Kevin M. El-Hayek1,2
1Section of Surgical Endoscopy, Department of General Surgery, Cleveland Clinic, Cleveland, OH; 2Surgery, Cleveland Clinic Lerner College of Medicine, Cleveland, OH; 3Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH; 4Digestive Disease Insititute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
Introduction: An array of foregut operations may produce chronic gastroparesis, putatively related to vagal denervation from either therapeutic transection or inadvertent injury. While promotility agents are first line therapy, efficacy decays over time. Some groups have recommended total gastrectomy with roux-en-Y reconstruction for this complex patient population. Previous evidence demonstrated a positive effect of laparoscopic pyloroplasty to improve gastric emptying and symptoms for patients with medically refractory post-surgical gastroparesis. Endoscopic per-oral pyloromyotomy (POP) is an emerging technique that obviates the need for surgical intervention. Here we present the largest series of patients who underwent POP for medically refractory post-surgical gastropareis at a single institution.
Methods: Patients identified from a prospectively maintained database of patients undergoing POP procedures at our institution from January 2016 to November 2017 were included. Patient demographics, comorbid conditions, and diagnostic tests were previously abstracted. Surgical history, operative details, and follow-up data to three months were additionally recorded.
Results: During the study period, 147 POP procedures were performed, of which 29 (19.7%) had post-surgical gastroparesis. The study cohort was 79.1% female with a mean body mass index of 28.0 kg/m2 and mean age of 55.5 years. Common comorbidities included hypertension (31.0%), depression (37.9%), fibromyalgia (20.7%), gastroesophageal reflux disease (17.2%) and diabetes (10.3%). In each case, diabetes developed after initial symptoms of gastroparesis. Eight-two percent of patients had either a paraesophageal hernia repair or fundoplication. Pyloric injection of botulinum toxin prior to POP was common (24.1%) and accounted for the majority of previous interventions to treat gastroparesis. The mean 4-hour gastric emptying was 49.7% (normal 90-100%) prior to POP. All but one case was performed in the operating room, and one had a concurrent removal of an adjustable gastric band. The mean operative time was 30 ±16 minutes. There were no intraoperative complications. Postoperative length of stay averaged 1.17 days. One patient was readmitted for melena that resolved without further intervention, and one patient needed intravenous hydration and there was one fatal perioperative myocardial infarction. The mean improvement in total Gastroparesis Symptom Index Score 90 days following the operation was 1.4 (p=0.0001). Gastric emptying improved to a mean of 19.5% in 9 patients, of whom 5 had completely normalized.
Conclusion: POP is a safe and effective endoscopic salvage therapy for post-surgical gastroparesis. This minimally invasive approach is a reasonable first-line option for patients with medically refractory gastroparesis.
| Female sex | 79.3% | | Mean Age (±SD) | 55.5 ± 14.2 | | Mean body mass index (±SD) | 28.0 ± 4.5 | | Comorbidities | | | Hypertension | 31.0% | | Gastroesophageal reflux disease | 17.2% | | Fibromyalgia | 20.7% | | Dyslipidemia | 17.2% | | Diabetes | 10.3% | | Irritable bowel syndrome | 6.8% | | Depression | 37.9% | | Anxiety | 17.2% | | Contributing surgeries | | | Vagotomy | 3.4% | | Hiatal or paraesophageal hernia repair | 41.3% | | Fundoplication alone | 41.3% | | Heller myotomy | 3.4% | | Other | 17.2% | | Prior interventions for gastroparesis | 34.4% | | Gastrostomy tube | 6.9% | | Jejunostomy tube | 3.4% | | Gastric electric stimulator | 3.4% | | Pyloric botulinum toxin injection | 24.1% | | Solid Phase Scintigraphic Emptying at 4 hours | 49.7% | | Mean operative time (minutes) | 30 ± 16 | | Mean Length of Stay (days) | 1.2 ± 1.1 | | Complications | | | Gastrointestinal bleed | 3.4% | | Readmission with 30 days related to POP | 3.4% | | | |
Gastroparesis Cardinal Symptom Index | | Pre | 90-Days Post Procedure | p-value | | Mean Total GCSI Score (±SD) | 3.82 ± 0.67 | 2.36 ± 1.21 | 0.0001 | | Mean Post Prandial Fullness Subscore (±SD) | 3.28 ± 0.94 | 1.68 ± 1.17 | 0.0002 | | Mean Nausea / Vomiting Subscore (±SD) | 3.91 ± 0.98 | 2.68 ± 1.52 | 0.0017 | | Mean Bloating Subscore (±SD) | 4.27 ± 1.12 | 2.73 ± 1.73 | 0.0022 |
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