Heineke, Mikulicz, Jaboulay, and Finney: Innovators of Surgical Pyloroplasty

Closure of large mucosal defects for prevention of strictures after duodenal endoscopic submucosal dissection (with video)

BACKGROUND AND AIMS

Although lesions occupying a large circumference are associated with the risk of post-endoscopic submucosal dissection (ESD) strictures, the corresponding data for duodenal lesions are unknown. We aimed to analyze the incidence of post-ESD strictures after wide-field duodenal ESD.

METHODS

In this retrospective study of duodenal lesions treated with ESD between July 2010 and August 2021, we included lesions that resulted in mucosal defects occupying more than half of the circumference and excluded lesions located in bulbs and involving Vater's papilla. We analyzed the incidence rates of stricture and luminal narrowing, in addition to bleeding and perforation as the outcomes in this study. Stricture was defined as the inability of the endoscope to pass through the lumen. A single endoscopist reviewed all endoscopic images and judged the degree of luminal narrowing.

RESULTS

Eighty lesions were included, of which 2 involved mucosal defects occupying more than 90% of the circumference. The wound was closed, at least partially, in 90% in all lesions and in 86% of lesions with a mucosal defect occupying more than 75% of the circumference. None of the lesions caused delayed perforation and stricture, whereas 2 lesions caused delayed bleeding. Only 6 lesions caused luminal narrowing. When examined by the degree of closure, the rate of luminal narrowing increased with complete closure, incomplete closure, and nonclosure (4.9%, 9.1%, and 25.0%, respectively).

CONCLUSIONS

Suturing may prevent post-ESD bleeding and perforation as well as stricture formation in cases of duodenal tumors, with mucosal defects occupying a large circumference.

Predictors of favorable outcome after pyloroplasty for gastroparesis: should response to pyloric dilation or Botox injection be used as a marker of surgical outcome?

INTRODUCTION

Pyloroplasty and gastric peroral endoscopic myotomy (G-POEM) are effective surgeries for gastroparesis. The primary aim of this study was to evaluate outcomes of pyloroplasty and G-POEM in patients with gastroparesis and determine factors associated with favorable outcome. The secondary aim was to assess the utility of clinical response to preoperative pyloric dilation or botulinum toxin injection (Botox) on surgical outcome, a factor conventionally used as a favorable marker.

METHODS

There were 204 patients who underwent pyloroplasty (n = 177) or G-POEM (n = 27) for gastroparesis at our institution from 2014 to 2021. Demographic and clinical parameters were analyzed to assess their impact on surgical outcome. A subgroup of patients who had pyloric dilation or Botox injection were assessed separately. Favorable outcome was defined as patient reported complete resolution of the predominant gastroparesis symptom.

RESULTS

Favorable outcome was achieved in 78.4% of patients (pyloroplasty: 79.7% and G-POEM: 70.4%, p = 0.274). Among 61 patients where pre- and postoperative gastric emptying studies (GES) were available, mean 4-hour retention significantly improved from 33.5 to 15.0% (p < 0.001) and 77.0% of patients achieved normalization. Favorable outcome was not significantly impacted by etiology of gastroparesis (p = 0.120), GERD (p = 0.518), or primary gastroparesis symptom (p = 0.244). Age ≥ 40 was a significant predictor of favorable surgical outcome on multivariate analysis [OR: 2.476 (1.224-5.008), p = 0.012]. Among the patients who had preoperative dilation (n = 82) or Botox injection (n = 46), response to these interventions was not a predictor of favorable surgical outcome (p = 0.192 and 0.979, respectively). However, preoperative Botox injection, regardless of response to injection, was associated with favorable surgical outcome [OR: 3.205 (CI 1.105-9.299), p = 0.032].

CONCLUSION

Symptomatic improvement after pyloroplasty or G-POEM is independent of etiology of gastroparesis, GERD, and primary symptom. Response to dilation or Botox are not markers of response to surgery. However, patients who receive Botox are 3.2 times more likely to improve postoperatively.

Acute gastric twist after laparoscopic sleeve gastrectomy: A case series

INTRODUCTION

Laparoscopic sleeve gastrectomy (LSG) has become the most performed bariatric procedure. Like any surgical intervention, LSG is not free from complications. One of the rarest complications is gastric sleeve stenosis, caused by either stricture or axial rotation of the stomach (twisted gastric tube). There is no consensus on the management of such a complication due to several underlying mechanisms and different timings of presentation.

METHODS

Between July 1, 2021 and December 31, 2021, we encountered three cases of acute gastric twist following LSG, and all of them required surgical intervention. All data (imaging results, operative reports and videos, discharge summaries, etc.) were retrospectively collected and analyzed after obtaining patients' informed consent.

RESULTS

We report three cases of acute gastric twist post-sleeve gastrectomy, diagnosed by different imaging modalities which showed localized distal gastric twist. All patients underwent exploratory laparoscopy which confirmed gastric sleeve twist. Gastropexy by fixation of the gastric tube to the transverse mesocolon was done in the first case which presented a localized partial distal twist, and a gastro-jejunal anastomosis proximal to the gastric twist was performed in the two other cases to bypass the obstruction. All of them had excellent postoperative results and a total symptomatic resolution.

CONCLUSION

We considered gastric tube fixation to the transverse mesocolon as a feasible option when the twist is local and partial. We also presented a new surgical modality to treat local complete distal gastric twist by a single gastro-jejunal latero-lateral anastomosis proximal to the twist, which seems safe and effective. The best method to treat such a complication is to prevent it by giving special attention to the different technical aspects of LSG.