Megan Sippey, MD, Mark Anderson, MD, Jeffrey Marks, MD, FASC, FASGE. Case Western Reserve University
Introduction: Delayed gastric emptying occurs in approximately 15-30% of patients following thoracoabdominal esophagectomy. This is predominantly due to inherent vagotomy. Patients have a decreased quality of life secondary to persistent nausea and intolerance of oral intake. Management options include dietary modifications, pro-motility agents, endoscopic balloon dilation, intra-pyloric Botox injections, and pyloroplasty.
Following the success of per oral endoscopic myotomy (POEM) for achalasia, the first gastric per oral pyloromyotomy (G-POP) was performed in 2013 for gastroparesis. Using a similar technique as POEM, a mucosotomy is made in the gastric antrum followed by dissection of a submucosal tunnel. Pyloric muscle fibers are then cauterized extending to the duodenum to assure a complete release of the pylorus. The mucosal defect at the tunnel entrance is then closed. G-POP provides an endoscopic alternative to a surgical pyloromyotomy or pyloroplasty, and can serve as salvage therapy following failed gastric emptying procedure at the time of esophagectomy.
Case: A 71yo male with a history of an Ivor Lewis esophagectomy with pyloroplasty in 2004 for long segment Barrett’s esophagus presented with post-vagotomy induced delayed gastric emptying with recurrent aspiration pneumonias. His past medical history includes GERD, hyperlipidemia, diabetes, coronary artery disease, and depression. In addition to the esophagectomy, his surgical history includes an appendectomy and cholecystectomy. He’s had multiple upper endoscopies with balloon dilation and Botox injections, which provided only temporary relief for approximately 6 weeks before return of symptoms. Gastric emptying study showed retention of 63% of radiotracer at 4 hours, consistent with severe disease.
G-POP was performed as outlined in the introduction. The patient’s unique post-surgical anatomy posed a few challenges: reduced ability to insufflate with decreased working space, and some tortuosity of the stomach with redundancy of the gastric folds such that visualization of the lesser curve antrum was difficult. Despite this, the G-POP was successfully performed with improvement in the patency of and ability to traverse the pylorus with the endoscope on completion of the pyloromyotomy.
Post-operative swallow study confirmed free flow of contrast through the stomach without evidence of obstruction. The patient had one readmission for aspiration pneumonia. He reports vomiting approximately once weekly, as opposed to three times weekly pre-operatively.
Conclusions: Delayed gastric emptying following esophagectomy is not uncommon, yet it can be a challenging entity to manage. G-POP is a technically challenging but feasible option that allows for decreased symptomatology and improved quality of life in this population.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 93898
Program Number: V134
Presentation Session: Flexible Endoscopy II
Presentation Type: Video