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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 sex79.3%
Mean Age (±SD)55.5 ± 14.2
Mean body mass index (±SD)28.0 ± 4.5
Comorbidities 
Hypertension31.0%
Gastroesophageal reflux disease17.2%
Fibromyalgia20.7%
Dyslipidemia 17.2%
Diabetes10.3%
Irritable bowel syndrome6.8%
Depression37.9%
Anxiety17.2%
Contributing surgeries 
Vagotomy3.4%
Hiatal or paraesophageal hernia repair41.3%
Fundoplication alone41.3%
Heller myotomy3.4%
Other17.2%
Prior interventions for gastroparesis34.4%
Gastrostomy tube6.9%
Jejunostomy tube3.4%
Gastric electric stimulator3.4%
Pyloric botulinum toxin injection24.1%
Solid Phase Scintigraphic Emptying at 4 hours49.7%
Mean operative time (minutes)30 ± 16
Mean Length of Stay (days)1.2 ± 1.1
Complications 
Gastrointestinal bleed3.4%
Readmission with 30 days related to POP3.4%
  


Gastroparesis Cardinal Symptom Index
 Pre90-Days Post Procedurep-value
Mean Total GCSI Score (±SD)3.82 ± 0.672.36 ± 1.210.0001
Mean Post Prandial Fullness Subscore (±SD)3.28 ± 0.941.68 ± 1.170.0002
Mean Nausea / Vomiting Subscore (±SD)3.91 ± 0.982.68 ± 1.520.0017
Mean Bloating Subscore (±SD)4.27 ± 1.122.73 ± 1.730.0022


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