Gastric Peroral Endoscopic Myotomy as a Therapeutic Option in Refractory Gastroparesis: A Step-By-Step Description.

Abstract

Gastroparesis is a chronic disorder characterized by delayed gastric emptying without evidence of stomach or proximal small intestine obstruction [1]. Its pathophysiology is unclear, although gastric arrhythmias, fundal and antral hypocontractility, pylorospasm, and antropyloroduodenal incoordination might be involved [1]. Dietary modifications and prokinetics are first-line treatments. When refractory gastroparesis is present, surgical or endoscopic treatment must be considered. We present a case of a 68-year-old female patient, followed in gastroenterology consult due to nausea, persistent postprandial vomiting, early satiety, and belching. She has no relevant past medical or surgical history or medication. Esophagogastroduodenoscopy revealed food stasis but was otherwise normal. Gastric emptying scintigraphy (GES) showed emptying of 30% at 156 min, 46% at 217 min, and 54% at 260 min, with significant radiopharmaceutical retention (46% at 4 h 18 min), translating scintigraphic evidence of delayed gastric emptying (Fig. 1). The diagnosis of gastroparesis was made, and medical therapy was optimized. She had no improvement after 6 months, traducing a Gastroparesis Cardinal Symptom Index (GCSI) score of 3.33 points (0–5 points) [2]. Idiopathic refractory gastroparesis was admitted, and gastric peroral endoscopic myotomy (G-POEM) was proposed. The procedure was performed with an endoscope (GIF-HQ190; Olympus Medical Systems, Tokyo, Japan), with a transparent distal cap (DH28GR; Fujifilm, Tokyo, Japan) and insufflation with CO2. The patient was under general anesthesia and orotracheal intubation. The VIO®3 (Erbe Elektromedizin GmbH, Tuebingen, Germany) was used as the electrosurgical unit. Antibiotic (cefotaxime 1 g) was administered. The procedure began with submucosal injection, in the greater gastric curvature, 5 cm proximal to the pylorus with a solution of 100