GASTRIC PERORAL ENDOSCOPY PYLOROMYOTOMY (G-POEM) FOR MANAGING REFRACTORY GASTROPARESIS CONSECUTIVE TO ESOPHAGEAL RESECTION: RESULTS FROM MULTICENTER SERIES

Introduction:
Severe gastroparesis (GP) is one of the major complications occurring in 15 to 40% of patients after esophagectomy with gastric pull-through despite recent progress in surgical techniques. GP significantly impacts the patients’ quality of life and nutritional status. Pylorospasm caused by bilateral vagotomy is believed to be an important pathophysiological factor responsible for development of GP in such situation. Endoscopic pyloromyotomy (G-POEM) has become promising treatment option for patients suffering from refractory GP. Thus, we aimed to assess the outcomes of this intervention for treating post-esophagectomy gastroparesis.
Patients and methods:
This is a retrospective multicenter observational study, conducted in 10 European expert centers. All analyzed patients had undergone esophagectomy for esophageal cancer and developed severe and refractory GP as assessed by the GCSI (Gastric Cardinal Symptomatic Index) score. The diagnosis was confirmed by delayed gastric emptying confirmed by scintigraphy (GES) and/or bezoar at gastroscopy. All patients underwent endoscopic pylorotomy with at least 6 months of follow-up.
The primary endpoint was clinical success rate at 6 months, defined as a GCSI decrease by at least 1 point from baseline. The secondary outcomes were: clinical success at the end of follow-up, safety, technical features and impact on weight and quality of life (QoL).
Results:
A total of 70 patients, 51% of men, with mean age of 65±11 years were analyzed. The mean time between surgery and symptoms onset was 13.8 ± 22.1 months.
The mean baseline half emptying time, and percentage of 2- and 4- hour residual activity were105.6 ± 104.8 min, 63.7 ± 29.3% and 64.8 ± 99%. The baseline mean GCSI score was 2.9 ± 0.95 and the mean QoL evaluation (10) was poor (2.8 ± 1.5).
G-POEM was feasible in all the cases, with single myotomy in 87% of cases, considered as more difficult than a regular procedure in 17% of cases mostly because of the angulation of the antrum. No severe adverse events were reported.
The clinical success rate at 6 months was 80% (n=56), with a significant decrease of GCSI to 1.1 ± 1.2 (p<0.001). QoL significantly improved (5.36 ± 2.2, p<0.001).
Mean follow-up was 18.4 ± 15.1 months, and the clinical success rate at last evaluation was 77%. A total of 72% patients increased weight with a mean increase of 3.9 ± 2 kilograms.
Conclusions:
Endoscopic pyloromyotomy is feasible, safe and effective for gastroparesis following esophageal resection.