PYloroplasty versus No Intervention in GAstric REmnant REconstruction after Oesophagectomy: study protocol for the PYNI-GAREREO phase III randomized controlled trial

BACKGROUND

After esophagectomy for esophageal and esophagogastric cancer, more than half of patients have lost > 10% of their body weight at 12 months. In most cases, the gastric remnant is used for reconstruction after esophagectomy. One of the most serious nutritional complications of this technique is delayed gastric emptying caused by gastric remnant mobilization and denervation of the vagus nerve. The aim of the PYloroplasty versus No Intervention in GAstric REmnant REconstruction after Oesophagectomy (PYNI-GAREREO) trial is to analyze the clinical outcome of modified Horsley pyloroplasty (mH-P) as a method of preventing delayed gastric emptying.

METHODS

The PYNI-GAREREO trial is designed as an open randomized, single-center superiority trial. Patients will be randomly allocated to undergo gastric remnant reconstruction with mH-P (intervention group) or no intervention (control group) in parallel groups. All patients with esophageal cancer or esophagogastric cancer planning to undergo curative minimally invasive esophagectomy will be considered for inclusion. A total of 140 patients will be included in the study and randomized between the groups in a 1:1 ratio. The primary outcome is the body weight change at 6 months postoperatively, and the secondary outcomes are the nutritional status, postoperative complications, functional outcome, and quality of life until 1 year postoperatively.

DISCUSSION

We hypothesize that mH-P after minimally invasive esophagectomy more effectively maintains patients' nutritional status than no pyloroplasty.

TRIAL REGISTRATION

UMIN Clinical Trials Registry UMIN000045104. Registered on 25 August 2021. https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000051346 .

[S156] Comparing outcomes of per-oral pyloromyotomy and robotic pyloroplasty for the treatment of gastroparesis

BACKGROUND

Gastroparesis is characterized by delayed gastric emptying without a significant obstructive pathology and is estimated to effect more than 5 million adults in the United States. Therapies for this condition are divided into two categories: gastric electrical stimulation or pyloric therapies to facilitate gastric emptying. Pyloric procedures include pyloroplasty, a well-documented procedure, and per-oral endoscopic myotomy (POP), a relatively novel endoscopic procedure that disrupts the pyloric muscles endoscopically. There is a paucity of literature comparing the two procedures. The aim of this study is to compare the outcomes of these two techniques.

METHODS

Under an IRB protocol, data were collected prospectively from September 2018 through April 2021 at our institution for patients undergoing POP (n = 63 patients) or robotic pyloroplasty (RP) (n = 48). Preoperative and postoperative data including sex, race, age, BMI, and Gastroparesis Cardinal Symptom Index (GCSI) score were analyzed using univariate and multivariate analysis.

RESULTS

There was no significant difference in sex, age, and BMI for both cohorts, but patients with RP were more likely to have private insurance, pre-op reflux, and PPI (p < .05 for all). Patients who underwent POP had significantly shorter operative time compared to RP (median 27 min vs 90, p < 0.001). The average change between preoperative and postoperative GCSI scores was significantly decreased for both interventions (POP mean = 8.2, RP 16.8, p < 0.001 both). However, comparing both data, RP has significantly better improvement in postoperative GCSI score than POP in both univariate (p < 0.001) and multivariate analysis (p = 0.030). This was reflected in the individual symptoms with nausea (p < 0.001), ability to finish meal (p = 0.037), abdomen visibly larger (p = 0.037) and bloating (p = 0.022) all showing improvement in both groups, but with RP having a more significant decrease in the scoring of these symptoms than POP. There was no significant difference in the number of postoperative complications (POP 19% vs RP 13%, p = 0.440).

CONCLUSION

Even though both interventions are significantly associated with improvement of symptoms in patients with gastroparesis, our data demonstrates that robotic pyloroplasty has a superior response in comparison to per-oral endoscopic myotomy for the management of these symptoms. Per-oral pyloromyotomy has a similar complication rate to robotic pyloroplasty with a shorter operative time.

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.

Outcomes of Intraoperative Pyloric Drainage on Delayed Gastric Emptying Following Esophagectomy: A Systematic Review and Meta-analysis

BACKGROUND

Intraoperative pyloric drainage in esophagectomy may reduce delayed gastric emptying (DGE) but is associated with risk of biliary reflux and other complications. Existing evidence is heterogenous. Hence, this meta-analysis aims to compare outcomes of intraoperative pyloric drainage versus no intervention in patients undergoing esophagectomy.

METHODS

PubMed/MEDLINE, Embase, Web of Science, and the Cochrane were searched from inception up to July 2022. Exclusion criteria were lack of objective evidence (e.g., symptoms of nausea or vomiting) of DGE. The primary outcome was incidence of DGE. Secondary outcomes were incidence of pulmonary complications, bile reflux, anastomotic leak, operative time, and mortality.

RESULTS

There were nine studies including 1164 patients (pyloric drainage n = 656, no intervention n = 508). Intraoperative pyloric drainage included pyloroplasty (n = 166 (25.3%)), pyloromyotomy (n = 214 (32.6%)), botulinum toxin injection (n = 168 (25.6%)), and pyloric dilatation (n = 108 (16.5%)). Pyloric drainage is associated with reduced DGE (odds ratio (OR): 0.54, 95% confidence interval (CI): 0.39-0.74, I² = 50%). There was no significant difference in incidence of pulmonary complications (OR: 0.74, 95% CI: 0.51-1.08; I² = 0%), biliary reflux (OR: 1.43, 95% CI: 0.80-2.54, I² = 0%), anastomotic leak (OR: 0.79, 95% CI: 0.48-1.29; I² = 0%), operative time (MD: + 22.16 min, 95% CI: - 13.27-57.59 min; I² = 76%), and mortality (OR: 1.13, 95% CI: 0.48-2.64, I² = 0%) between the pyloric drainage and no intervention groups.

CONCLUSIONS

Pyloric drainage in esophagectomy reduces DGE but has similar post-operative outcomes. Further prospective studies should be carried out to compare various pyloric drainage techniques and its use in esophagectomy, especially minimally-invasive esophagectomy.

Are intra-operative gastric drainage procedures necessary in esophagectomy: a systematic review and meta-analysis

PURPOSE

Surgical pyloroplasty or pyloromyotomy are often performed during esophagectomy with a view of improving gastric conduit drainage. However, the clinical importance of this is not clear, and some centers opt to omit this step. The aim of this meta-analysis is to compare the rates of pulmonary complications, anastomotic leak, mortality, delayed gastric emptying, and the need for further pyloric intervention, in patients undergoing esophagectomy with and without a drainage procedure.

METHODS

A database search of Medline, EMBASE, and Cochrane Library was performed to identify randomized control trials and cohort studies published between 2000 and 2020 which compared outcomes of esophagectomy with and without drainage procedures. A random-effects meta-analysis model was used to compare the rates of pulmonary complications, anastomotic leak, mortality, delayed gastric emptying, and the need for further pyloric intervention.

RESULTS

Three randomized and 12 non-randomized publications were identified, comprising a total of 2339 patients. No significant differences were found between the two groups with regard to pulmonary complications (RR 1.02 [95% CI, 0.78-1.33], p = 0.91), anastomotic leak (RR 1.14 [95% CI, 0.80-1.62], p = 0.48), mortality (RR 0.53 [95% CI, 0.23-1.26], p = 0.15), delayed gastric emptying (RR 0.98 [95% CI, 0.59-1.62], p = 0.93), and the need for further pyloric intervention (RR 1.99 [95% CI, 0.56-7.08], p = 0.29).

CONCLUSION

Where post-operative pyloric treatment is available on demand, surgical pyloric drainage procedures may not have any significant clinical impact on patient outcomes for patients undergoing esophagectomy, though further good-quality randomized controlled trials are needed to confirm this.

Sleeve Gastrectomy with Pyloroplasty in Wistar Rats: Assessment of Gastric Emptying, Intestinal Transit, and Possible Duodenogastric Alkaline Reflux

BACKGROUND

Studies indicate sleeve gastrectomy (SG) as a factor of aggravation or even emergence of symptoms of gastroesophageal reflux disease. Accelerated gastric emptying is described as a mitigating factor. SG may be potentiated by adding a pyloroplasty, although with the potential risk of resulting in duodenogastric alkaline reflux. The objective was to standardize sleeve gastrectomy with pyloroplasty in rats, analyze the complementation in terms of mortality and weight evolution, and conduct assessments on gastric emptying, intestinal transit, and genesis of possible duodenogastric reflux.

METHODS

Ninety-three male Wistar rats were divided into a pilot study (standardization of the surgical technique and the scintigraphic study), and the main study. They were then subdivided into the SHAM group, the sleeve gastrectomy (SG) group, and the sleeve gastrectomy with pyloroplasty (SGP) group. After 3 months, the animals were submitted to two scintigraphic experiments and histological analysis of gastric biopsies.

RESULTS

The surgical groups (SG and SGP) lost initially more weight than the SHAM group, and the gastric emptying and intestinal transit in the first were more accelerated. However, no difference was found between the SG and SGP groups. Scintigraphic and histological analyses did not reveal statistical differences among the SG and SGP groups regarding gastroesophageal and duodenogastric refluxes.

CONCLUSIONS

Pyloroplasty did not affect weight reduction or increase duodenogastric reflux, after three postoperative months in this animal model of sleeve gastrectomy.

Gastric per-oral endoscopic myotomy: Indications, technique, results and comparison with surgical approach

Gastroparesis is a chronic disease of the stomach that causes a delayed gastric emptying, without the presence of a stenosis. For 30 years the authors identified pylorospasm as one of the most important pathophysiological mechanisms determining gastroparesis. Studies with EndoFLIP, a device that assesses pyloric distensibility, increased the knowledge about pylorospasm. Based on this data, several pyloric-targeted therapies were developed to treat refractory gastroparesis: Surgical pyloroplasty and endoscopic approach, such as pyloric injection of botulinum and pyloric stenting. Notwithstanding, the success of most of these techniques is still not complete. In 2013, the first human gastric per-oral endoscopic myotomy (GPOEM) was performed. It was inspired by the POEM technique, with a similar dissection method, that allows pyloromyotomy. Therapeutical results of GPOEM are similar to surgical approach in term of clinical success, adverse events and post-surgical pain. In the last 8 years GPOEM has gained the attention of the scientific community, as a minimally invasive technique with high rate of clinical success, quickly prevailing as a promising therapy for gastroparesis. Not surprisingly, in referral centers, its technical success rate is 100%. One of the main goals of recent studies is to identify those patients that will respond better to the therapies targeted on pylorus and to choose the better approach for each patient.

A history of the surgical correction of pyloric stenosis

Infantile hypertrophic pyloric stenosis (IHPS) is a complex disorder with an incidence from 4 to 5 per 1000 live births with a strongly male predilection. The natural history of this initially fatal condition with nearly 100% mortality has evolved to a disease with a good prognosis. Pyloromyotomy by Ramstedt was first described 110 years ago and still remains the standard of surgical treatment for patients with IHPS. The laparoscopic approach is becoming more common and is the preferred method of treatment now in many centres.

EndoFLIP and Pyloric Dilation for Gastroparesis Symptoms Refractory to Pyloromyotomy/Pyloroplasty

BACKGROUND

Gastroparesis patients may undergo pyloromyotomy/pyloroplasty for chronic refractory symptoms. However, some patients have persistent symptoms. It is unknown if balloon dilation may improve their symptoms.

AIMS

We aimed to (1) assess if pyloric through-the-scope (TTS) balloon dilation results in symptom improvement in gastroparesis patients with suboptimal response to pyloromyotomy/pyloroplasty and (2) determine endoscopic functional luminal imaging probe (EndoFLIP) characteristics of these patients before dilation.

METHODS

Patients with severe gastroparesis refractory to pyloromyotomy/pyloroplasty seen from 2/2019 to 3/2020 underwent pyloric TTS dilation after assessing the pyloric characteristics using EndoFLIP. Patients completed Gastroparesis Cardinal Symptom Index (GCSI) pre-procedurally, and GCSI and Clinical Patient Grading Assessment Scale (CPGAS) on follow-ups.

RESULTS

Thirteen (ten females) patients (mean age 45.2 ± 5.1 years) with severe gastroparesis symptoms (mean GCSI total score 3.4 ± 0.3) after pyloromyotomy/pyloroplasty underwent pyloric TTS dilation. Overall, there was improvement in symptoms at 1-month follow-up (mean GCSI total score 3.0 ± 0.4, mean CPGAS score 1.6 ± 0.5, p < 0.05 for both), with five (38%) patients reporting symptoms somewhat/moderately better. The patients with symptom improvement had lower pre-dilation pyloric EndoFLIP distensibility at 30 ml, 40 ml, and 50 ml than patients with little/no improvement (all p < 0.05).

CONCLUSIONS

In gastroparesis patients with refractory symptoms after pyloromyotomy/pyloroplasty, pyloric TTS dilation improved symptoms in about a third of the patients. Patients with symptom improvement had lower pre-dilation pyloric distensibility on EndoFLIP suggesting incomplete myotomy, pyloric muscle regeneration, or pyloric stricture. Pyloric EndoFLIP followed by TTS dilation seems to be a promising treatment for some patients with gastroparesis symptoms refractory to pyloromyotomy/pyloroplasty.

Medical and surgical management of gastroparesis: a systematic review

BACKGROUND

Gastroparesis (GPS) is a rare disease with multiple etiologies that results in delayed gastric emptying. Diagnosis of GPS can be challenging due to its rather complex clinical presentation. Pharmacologic refractory cases require surgical interventions, all of which have yet to be standardized and characterized.

OBJECTIVES

We present a review of the literature and provide an update of current therapies for patients with GPS.

SETTING

Department of General Surgery, Academic Hospital, United States.

METHODS

We conducted a comprehensive search in PubMed, Google Scholar, and Embase of English-written articles published in the last 38 years, with an advance title search of "gastroparesis management." Other keywords included: "surgical management" and "refractory gastroparesis." Further references were obtained through cross-reference.

RESULTS

A total of 12,250 articles were selected after eliminating duplicates. Following thorough screening of selection criteria, 68 full-text articles were included for review.

CONCLUSION

GPS is a challenging disease to manage. Nutritional support must remain the primary approach, followed by either medical or surgical treatment modalities if necessary. In patients with refractory gastroparesis, adjunctive therapies have been proposed as promising long-term options.

Surgical Treatment for Refractory Gastroparesis: Stimulator, Pyloric Surgery, or Both?

BACKGROUND

Several surgical options exist for refractory gastroparesis (Gp) including gastric electric stimulation (GES) and pyloric surgery (PS) such as pyloromyotomy or pyloroplasty. Few studies exist comparing the outcomes of these surgeries.

AIM

Compare the clinical outcomes of GES, PS, and simultaneous GES+PS for refractory Gp.

METHODS

Patients undergoing surgical intervention at our medical center from January 2016 to April 2019 were given pre- and post-surgery questionnaires to assess their response to intervention: Patient Assessment of Upper Gastrointestinal Symptoms (PAGI-SYM) grading symptoms and Clinical Patient Grading Assessment Scale (CPGAS) grading response to treatment. Results are expressed as mean ± SE.

RESULTS

One hundred thirty-two patients underwent surgical intervention; 12 were excluded. Mean CPGAS improvement overall was 2.8 ± 0.2 (p < 0.01): GES+PS had CPGAS score at 3.6 ± 0.5, pyloric interventions 3.1 ± 0.5, and GES 2.5 ± 0.4 (p > 0.05). Mean improvement in Gastroparesis Cardinal Symptom Index (GCSI) total score was 1.0 ± 0.1 (p < 0.01), with improvement of 1.1 ± 0.2 for GES + PS, 0.9 ± 0.2 for GES, and 0.9 ± 0.2 for PS (p > 0.05). GES and GES + PS, but not PS only, significantly improved symptoms of nausea and vomiting (p < 0.01). Among gastroparesis subtypes, patients with diabetic gastroparesis had more improvement on nausea/vomiting subscale compared with idiopathic gastroparesis (p = 0.028).

CONCLUSIONS

Patients with refractory symptoms of Gp undergoing GES, PS, or combined GES+PS each had significant improvement of their GCSI total score. GES and combined GES+PS significantly improved nausea/vomiting. These results suggest GES or combined GES+PS appears better for nausea/vomiting predominant refractory Gp.

Endoscopic and Surgical Treatments for Gastroparesis: What to Do and Whom to Treat?

Gastroparesis is a complex chronic debilitating condition of gastric motility resulting in the delayed gastric emptying and multiple severe symptoms, which may lead to malnutrition and dehydration. Initial management of patients with gastroparesis focuses on the diet, lifestyle modification and medical therapy. Various endoscopic and surgical interventions are reserved for refractory cases of gastroparesis, not responding to conservative therapy. Pyloric interventions, enteral access tubes, gastric electrical stimulator and gastrectomy have been described in the care of patients with gastroparesis. In this article, the authors review current management, indications, and contraindications to these procedures.

Obstructive Gastroparesis: Patient Selection and Effect of Laparoscopic Pyloroplasty

BACKGROUND

Functional obstructive gastroparesis is an understudied subtype of gastroparesis with normal 3 cycle per minute gastric myoelectrical activity that responds to botulinum toxin A injection and balloon dilation of the pylorus.

AIMS

To determine the effect of pyloroplasty on symptoms, weight, gastric emptying, and gastric myoelectrical activity in patients with gastroparesis and normal 3 cycle per minute gastric myoelectrical activity.

METHODS

Ten patients (average age 36 years with gastroparesis and normal 3 cycle per minute gastric myoelectrical activity) who had at least two successful endoscopic pyloric therapies and then underwent pyloroplasty were identified. Electrogastrography with water load satiety test was performed to determine gastric myoelectrical activity. Gastric emptying was measured with 4-h scintigraphy.

KEY RESULTS

Six months after pyloroplasty, nine of ten patients reported improved symptoms and weight increased an average of 6.4 lb (p = 0.04). The average percentage of meal retained at 4 h decreased from 47% before to 16% after pyloroplasty (p < 0.01) and normalized in six patients. After pyloroplasty, the percent distribution of gastric myoelectrical activity power in the 3 cycle per minute range decreased at each measured interval compared with pre-pyloroplasty (p < 0.01).

CONCLUSIONS

(1) Pyloroplasty in these patients with obstructive gastroparesis improved gastric emptying and decreased 3 cycle per minute gastric myoelectrical activity, consistent with relief of functional gastric outlet obstruction. (2) Pyloric neuromuscular dysfunction is a key factor in delayed emptying in patients with functional obstructive gastroparesis.

Patient factors influence surgical options in gastroparesis

BACKGROUND

Patient selection for the diverse surgical procedures for gastroparesis remains poorly defined. Our aim was to evaluate how patient factors have determined our surgical approach to gastroparesis.

METHODS

95 patients undergoing 105 surgical procedures for gastroparesis were reviewed. Patient factors were compared across six surgical procedures: gastric neurostimulator, pyloroplasty, neurostimulator plus pyloroplasty, sleeve gastrectomy, gastric bypass and gastrectomy. Global symptom severity was determined preoperatively and at last follow up.

RESULTS

There were significant differences in etiology, BMI and gastroesophageal reflux across the various operations. Patients undergoing pyloroplasty and gastrectomy; were more likely to have a postsurgical etiology. (p < .05) Patients undergoing sleeve gastrectomy and gastric bypass were more likely to have BMI >35. ^{(p <.05)} Those undergoing sleeve gastrectomy were less likely to have gastroesophageal reflux preoperatively. ^{(p <.05)} There was no difference in preoperative clinical stage across the procedures.

CONCLUSION

Patient factors influence choice of procedure in the surgical treatment of gastroparesis. Etiology of gastroparesis, BMI >35 and gastroesophageal reflux are important determinants.

Primary acquired gastric outlet obstruction in children: A retrospective single center study

BACKGROUND/ PURPOSE

Idiopathic hypertrophic pyloric stenosis is by far the most common cause of gastric outlet obstruction (GOO) in young infants, with more than 90% of cases presenting between 3 and 10 weeks after birth. While cases of late onset pyloric stenosis beyond infancy have been reported, the etiology is poorly understood. We report our experience of 5 cases, describing the similarities and differences in management of our patient population which happens to be the second largest reported in literature.

METHODS

From July 2014 to June 2018 (4 years) a total of five patients of primary acquired GOO were encountered at our center.

RESULTS

The age range was 3 to 6 years and only one of them was a female. All presented with characteristic nonbilious vomiting that was recurrent and episodic. Upper GI (gastrointestinal) contrast study series revealed a dilated stomach and delayed gastric emptying. Upper GI endoscopy also demonstrated a dilated stomach without any intraluminal polyp, ulcer or any other pathology. Intraoperatively the pylorus had no evidence of scarring, inflammation, external compression or any mass in and around the pylorus. A retrocolic gastrojejunostomy was curative in all patients.

CONCLUSION

Though rare, one must maintain a high index of suspicion for primary acquired GOO in the differential diagnosis of older children with nonbilious vomiting and failure to thrive. Following appropriate diagnostic workup, surgical interventions should be performed expeditiously because adequate nutrition is key to proper physical and mental development of the child. Further research will hopefully elucidate the underlying pathophysiology in order to guide clinical options for both prevention and treatment.

TYPE OF STUDY

Retrospective single center study.

LEVEL OF EVIDENCE

Level 4.

Clinical efficacy of gastric per-oral endoscopic myotomy (G-POEM) in the treatment of refractory gastroparesis and predictors of outcomes: a systematic review and meta-analysis using surgical pyloroplasty as a comparator group. Surg Endosc. 2019; Epub ahead of print. [PMID: 31583465 DOI: 10.1007/s00464-019-07135-9]

BACKGROUND AND AIMS

Gastric peroral endoscopic myotomy (G-POEM) is a novel minimally invasive technique in endosurgery. Data is limited as to its efficacy, safety, and predictive factors. We conducted this meta-analysis to evaluate the clinical outcomes of G-POEM and used the outcomes of surgical pyloroplasty as a comparator group in the treatment of refractory gastroparesis.

METHODS

We searched multiple databases from inception through March 2019 to identify studies that reported on G-POEM and pyloroplasty in gastroparesis. Our primary outcome was to analyze and compare the pooled rates of clinical success, in terms of Gastroparesis Cardinal Symptom Index (GCSI) score and 4-h gastric emptying study (GES) results, with G-POEM and pyloroplasty.

RESULTS

Three hundred and thirty-two and 375 patients underwent G-POEM (11 studies) and surgical pyloroplasty (seven studies), respectively. The pooled rate of clinical success, based on the GCSI score, with G-POEM was 75.8% (95% CI 68.1-82.1, I² = 50) and with surgical pyloroplasty was 77.3% (95% CI 66.4-85.4, I² = 0), with no significance, p = 0.81. The pooled rate of clinical success, based on the 4-hour GES results, with G-POEM was 85.1% (95% CI 68.9-93.7, I² = 74) and with surgical pyloroplasty was 84% (95% CI 64.4-93.8, I² = 81), with no significance, p = 0.91. The overall adverse events were comparable. Based on meta-regression analysis, idiopathic gastroparesis, prior treatment with botulinum toxin and gastric stimulator seemed to predict clinical success with G-POEM.

CONCLUSION

G-POEM demonstrates clinical success in treating refractory gastroparesis. Idiopathic gastroparesis, prior treatment with botulinum injections and gastric stimulator appear to have positive predictive effects on the 4-h GES results after G-POEM. Outcomes seem comparable to surgical pyloroplasty.

Clinical outcomes and molecular profile of patients with Carmi syndrome: A systematic review and evidence quality assessment

PURPOSE

Carmi syndrome is a rare genetic disorder characterized by junctional epidermolysis bullosa (JEB) and pyloric atresia (PA). We reviewed the clinicopathologic and molecular features of patients with Carmi syndrome to identify predictors of clinical outcome and guide surgical PA repair.

METHODS

A PRISMA-compliant systematic literature review of PubMed, CINAHL, and the Cochrane Library was performed.

RESULTS

63 original studies including a total of 100 patients were included. PA type 1 and 2 were equally prevalent (47.2%, 95% CI: 34.4-60.3). Heineke-Mikulicz pyloroplasty (96%, 95% CI: 78.8-99) and gastroduodenostomy (72%, 95% CI: 52.2-85.9) were the most common type 1 and 2 PA repairs, respectively. Seventy lethal cases were identified (74.5%, 95% CI: 64.8-83.5). Of the 73 patients that received an operation, 49 died (67.1%, 95% CI: 55.7-76.8) and 24 survived (32.9%, 95% CI: 23.2-44.3). Integrin α6β4 expression was absent or markedly reduced in lethal cases. Integrin α6, plectin-1, cephalic integrin β4 (exon 3 to intron 11), and premature termination codon mutations were also associated with poor prognosis.

CONCLUSIONS

Although Carmi syndrome typically has poor prognosis, 1 in 4 patients exhibits nonlethal phenotypes. Immunofluorescence mapping and genetic consultation can guide surgical intervention and provide valuable family planning information.

EVIDENCE RATING/CLASSIFICATION

Prognosis study, Level IV.

Hybrid endoluminal stapled pyloroplasty: an alternative treatment option for gastric outlet obstruction syndrome

BACKGROUND

Gastroparesis is a rapidly increasing problem with sometimes devastating consequences. While surgical treatments, particularly laparoscopic pyloroplasty, have recently gained popularity, they require general anesthesia, advanced skills, and can lead to leaks. Peroral pyloromyotomy is a less invasive alternative; however, this technique is technically demanding and not widely available. We describe a hybrid laparo-endoscopic collaborative approach using a novel gastric access device to allow endoluminal stapled pyloroplasty as an alternative treatment option for gastric outlet obstruction.

METHODS

Under general anesthesia, six pigs (mean weight 33 kg) underwent endoscopic placement of intragastric ports using a technique similar to percutaneous endoscopic gastrostomy. A 5 mm laparoscope was used for visualization. A functional lumen imagine probe was used to measure the cross-sectional area (CSA) and diameter of the pylorus before, after, and at 1 week after intervention. Pyloroplasty was performed using a 5 mm articulating laparoscopic stapler. Gastrotomies were closed by endoscopic clips, endoscopic suture, or combination. After 6-8 days, a second evaluation was performed. At the end of the protocol, all animals were euthanized.

RESULTS

Six pyloroplasties were performed. In all cases, this technique was effective in achieving significant pyloric dilatation. The median pre-pyloroplasty pyloric diameter (D) and cross-sectional area (CSA) were 8 mm (4.9-11.6 mm) and 58.6 mm² (19-107 mm²), respectively. After the procedure, these values increased to 13.41 mm (9.8-17.6 mm) and 147.7 mm² (76-244 mm²), respectively (p = 0.0152). No important intraoperative events were observed. Postoperatively, all animals did well, with adequate oral intake and no relevant complications. At follow-up endoscopy, all incisions were healed and the pylorus widely patent.

CONCLUSIONS

Hybrid endoluminal stapled pyloroplasty is a feasible, safe, and effective alternative method for the treatment of gastric outlet obstruction syndrome.

Surgical Management for Gastroparesis

Gastroparesis is a debilitating chronic condition of indeterminate cause. Although conservative management is the mainstay of treatment, a significant percentage of patients will need interventions. Interventions range from supportive measures, such as feeding tubes, to more radical surgeries, including endoscopic pyloromyotomy (per oral pyloromyotomy), laparoscopic pyloroplasty, laparoscopic gastric stimulator placement, and even subtotal or total gastrectomy. The authors present some current treatment algorithms focused on the treatment side of the spectrum along with outcomes data to support the various approaches.

Intraoperative Pyloric Interventions during Oesophagectomy: a Multicentre Study

BACKGROUND

Denervation of the pylorus after oesophagectomy is considered the principal factor responsible for delayed gastric emptying. Several studies have attempted to delineate whether surgical or chemical management of the pylorus during oesophagectomy is of benefit, but with conflicting results. The aim of this multicentre study was to assess whether there was any difference in outcomes between different approaches to management of the pylorus.

METHODS

A prospectively maintained database was used to identify patients who underwent oesophagectomy for malignancy. They were divided into separate cohorts based on the specific pyloric intervention: intra-pyloric botulinum toxin injection, pyloroplasty and no pyloric treatment. Main outcome parameters were naso-gastric tube duration and re-siting, endoscopic pyloric intervention after surgery both as in- and outpatient, length of hospital stay, in-hospital mortality and delayed gastric emptying symptoms at first clinic appointment.

RESULTS

Ninety patients were included in this study, 30 in each group. The duration of post-operative naso-gastric tube placement demonstrated significance between the groups (p = 0.001), being longer for patients receiving botulinum treatment. The requirement for endoscopic pyloric treatment after surgery was again poorer for those receiving botulinum (p = 0.032 and 0.003 for inpatient and outpatient endoscopy, respectively).

CONCLUSION

We did not find evidence of superiority of surgical treatment or botulinum toxin of the pylorus, as prophylactic treatment for potential delayed gastric emptying after oesophagectomy, compared to no treatment at all. Based on our findings, no treatment of the pylorus yielded the most favourable outcomes.

Outcomes of surgical intervention for refractory gastroparesis: a systematic review

BACKGROUND

Gastroparesis (GP) is characterized by delayed gastric emptying with symptoms of nausea, vomiting, early satiety, postprandial fullness, and abdominal pain. Various surgical options exist to treat GP not responding to medical treatments (refractory GP), including gastric electric stimulation (GES), gastrectomy (GTx), and pyloric interventions (PI), whereas the outcomes of these procedures have been published; few comparison studies exist.

METHODS

PubMed literature review for articles from September 1988 to October 2017 was performed for prospective and retrospective analyses reporting >5 patients. Unweighted (per study) and weighted (per patient) overall improvement and improvement in symptoms of nausea, vomiting, and abdominal pain were calculated and compared for the different procedures.

RESULTS

Of 325 studies satisfying search criteria, 38 met the study criteria and were included for analysis. Total response to intervention, both weighted and unweighted, was greater with PIs compared to GES (P < 0.05). For unweighted symptom improvements, nausea improved more with PI than with GES (P < 0.05). GES improved vomiting more than epigastric pain (P < 0.05). For weighted symptom improvements, pyloric surgery and GTx improved vomiting compared to GES (P < 0.05).

CONCLUSIONS

Published outcomes of GES, pyloric surgery, and GTx for refractory GP are compared. Pyloromyotomy/pyloroplasty improves patient response greater than with GES. Weighing by number of studies, pyloric surgery improves nausea and abdominal pain greater than GES. For GES, vomiting is more likely to improve than abdominal pain. Weighing by number of patients, pyloric surgery and GTx improved vomiting compared to GES.

Surgical management of corrosive-induced gastric injury in children: 10years' experience

AIM

The purpose of this study was to report surgical management and outcome of corrosive-induced gastric injuries in children at our institute over the last decade.

PATIENTS & METHOD

Medical records of patients admitted for corrosive-induced gastric injury at the Pediatric Surgery Department of Ain Shams University between January 2007 and January 2017 were retrospectively reviewed.

RESULTS

Twenty six cases (17 boys and 9 girls) were enrolled. Mean age was 3.61±1.29. Ingested agent was acid in all the patients. Main presenting symptom was gastric output obstruction in 22 cases. The interval between corrosive ingestion and presentation ranged from one to 135days (mean=43.9±34). Surgical procedure included total gastrectomy (n=2), partial gastrectomy (n=2), augmentation gastroplasty (n=1), Billroth I (n=2), antrectomy (n=2), antroplasty (n=3), gastrojejunostomy (n=2), Heineke-Mikulicz pyloroplasty (n=9), Finney pyloroplasty (n=5), and feeding jejunostomy (n=4). Anastomotic stricture requiring a second operation developed in one patient. There were three mortalities related to the associated esophageal strictures. The mean follow-up period is 3.5years. All patients are free of symptoms and gained adequate weight.

CONCLUSION

Surgery is the mainstay of management for corrosive-induced gastric injuries with good long-term results. Surgical procedure should be tailored according to the patient's general condition and extent of gastric injury.

LEVEL OF EVIDENCE

This is a case series with no comparison group (level IV).

Pylorus drainage procedures in thoracoabdominal esophagectomy - a single-center experience and review of the literature

BACKGROUND

Pylorotomy and pyloroplasty in thoracoabdominal esophagectomy are routinely performed in many high-volume centers to prevent delayed gastric emptying (DGE) due to truncal vagotomy. Currently, controversy remains regarding the need for these practices. The present study aimed to determine the value and role of pyloric drainage procedures in esophagectomy with gastric replacement.

METHODS

A retrospective review of prospectively collected data was performed for all consecutive patients who underwent thoracoabdominal resection of the esophagus between January 2009 and December 2016 at the Katharinenhospital in Stuttgart, Germany. Clinicopathologic features and surgical outcomes were evaluated with a focus on postoperative nutrition and gastric emptying.

RESULTS

The study group included 170 patients who underwent thoracoabdominal esophageal resection with a gastric conduit using the Ivor Lewis approach. The median age of the patients was 64 years. Most patients were male (81%), and most suffered from adenocarcinoma of the esophagus (75%). The median hospital stay was 20 days, and the 30-day hospital death rate was 2.9%. According to the department standard, pylorotomy, pyloroplasty, or other pyloric drainage procedures were not performed in any of the patients. Overall, 28/170 patients showed clinical signs of DGE (16.5%).

CONCLUSIONS

In the literature, the rate of DGE after thoracoabdominal esophagectomy is reported to be approximately 15%, even with the use of pyloric drainage procedures. This rate is comparable to that reported in the present series in which no pyloric drainage procedures were performed. Therefore, we believe that pyloric drainage procedures may be unwarranted in thoracoabdominal esophagectomy. However, future randomized trials are needed to ultimately confirm this supposition.

Gastric Peroral Endoscopic Pyloromyotomy Therapy for Refractory Gastroparesis

OPINION STATEMENT

Purpose of review Gastroparesis is a complex dysmotility disorder in which a number of normal gastric emptying mechanisms can be affected. The pylorus as an apparatus is particularly important since it stands as the last final gateway for gastric emptying. As such, pyloric interventions seem to be successful in reducing symptoms and also improving emptying of solids, an effect not observed with other medical interventions. Recent findings Gastric peroral endoscopic myotomy (G-POEM) is a novel technique which offers the promise of mimicking the success of a traditional surgical pyloroplasty, while embracing the minimally invasive paradigm of flexible endoscopic surgery. Emerging data seems to suggest that not only does G-POEM offer symptomatic and clinical improvement but also objective improvement in follow-up gastric emptying studies in as much as 70% of patients. Summary We believe that with proper patient selection, G-POEM will become a powerful tool for gastroenterologists managing this chronic debilitating disease.

Tailored approach to gastroparesis significantly improves symptoms

BACKGROUND

Gastroparesis is difficult to treat and many patients do not report relief of symptoms with medical therapy alone. Several operative approaches have been described. This study shows the results of our selective surgical approach for patients with gastroparesis.

MATERIALS AND METHODS

This is a retrospective study of prospective data from our electronic medical record and data symptom sheet. All patients had a pre-operative gastric emptying study showing gastroparesis, an esophagogastroduodenoscopy, and either a CT or an upper GI series with small bowel follow-through. All patients had pre- and post-operative symptom sheets where seven symptoms were scored for severity and frequency on a scale of 0-4. The scores were analyzed by a professional statistician using paired sample t test.

RESULTS

58 patients met inclusion criteria. 33 had gastric stimulator (GES), 7 pyloroplasty (PP), 16 with both gastric stimulator and pyloroplasty (GSP), and 2 sleeve gastrectomy. For patients in the GSP group, the second procedure was performed if there was inadequate improvement with the first procedure. There was no mortality. The follow-up period was 6-316 weeks (mean 66.107, SD 69.42). GES significantly improved frequency and severity for all symptoms except frequency of bloating and postprandial fullness. PP significantly improved nausea and vomiting severity, frequency of nausea, and early satiety. Symptom improvement for GSP was measured from after the first to after the second procedure. GSP significantly improved all but vomiting severity and frequency of early satiety, postprandial fullness, and epigastric pain.

CONCLUSION

All procedures significantly improved symptoms, although numbers are small in the PP group. GES demonstrates more improvement than PP, and if PP or GES does not adequately improve symptoms GSP is appropriate. In our practice, gastrectomy was reserved as a last resort.

The Long-Term Efficacy and Safety of Pyloroplasty Combined with Gastric Electrical Stimulation Therapy in Gastroparesis

INTRODUCTION

Gastroparesis is delayed gastric emptying without mechanical obstruction. Symptomatic improvement can be 50-60% with gastric electrical stimulation. To address delayed gastric emptying, pyloroplasty was added. This study examines the long-term efficacy and safety of simultaneous gastric electrical stimulator implantation and pyloroplasty.

METHODS

In this prospective single-arm trial conducted from 2012 to 2015, 27 [23 females; mean age 43 (22-63)] gastroparesis patients who underwent simultaneous gastric electrical stimulator implantation with Heineke-Mikulicz pyloroplasty were studied. Six (25%) underwent simultaneous robot-assisted pyloroplasty and gastric electrical stimulator implantation. Diagnosis of gastroparesis was based on the 4-h gastric emptying test defined as >60% retention of isotope at 2 h and >10% at 4 h. Total symptom scores assessing severity of nausea, early satiety, bloating, vomiting, post-prandial fullness, and epigastric pain were obtained at baseline and at follow-up visits, ranging from 3 to 38 months (mean: 17).

RESULTS

Follow-up data from 24 patients were available for analysis. There was 71% improvement in total symptom score on follow-up. Mean retention decreased by 29.6 and 48.7% at 2 and 4 h and gastric emptying was normalized in 60%. There were no post-surgical complications.

CONCLUSIONS

Combination of gastric electrical stimulator and pyloroplasty significantly accelerated gastric emptying and improved gastroparesis symptoms. Combining these two surgical therapies improves both subjective and objective endpoints in drug refractory gastroparesis.

Pyloric Therapies for Gastroparesis

OPINION STATEMENT

Gastroparesis is a syndrome that can be difficult to treat effectively and likely represents the common clinical presentation of multiple underlying mechanisms. One of these presumed mechanisms involves pyloric dysfunction, tied perhaps to spasm or fibrosis, manifesting as functional gastric outlet obstruction. Various diagnostic modalities have been used to better characterize this hypothesized abnormality, including most recently antroduodenal manometry and impedance planimetry. A variety of therapeutic interventions specific to the pylorus have also been proposed in the last several years, including intrapyloric injections of botulinum toxin, transpyloric stenting, surgical pyloroplasty, and endoscopic pyloromyotomy. The clinical application of these maneuvers has been mostly empiric thus far, but efforts are ongoing to identify the subset of patients whose physiology best positions them to benefit from such therapy. Early results for many of these interventions have been promising and will serve as the basis for larger and more systematic research frameworks moving forward.

Congenital pyloric atresia: Early and delayed presentations-A single centre experience of a rare anomaly

Pyloric atresia may occur as an isolated or pure atresia or may be associated with other anomalies like those involving skin, renal or gastrointestinal systems etc. The most frequent association is with junctional epidermolysis bullosa, a rare autosomal recessive disorder affecting the skin and mucosa. We present a prospective evaluation of three patients of pyloric atresia at our institute over last 2 years (2012-2014)-one of them presenting at 5th day of life and the other two at 5 and 6 years of age, respectively. Two of them did not have any other associated anomaly whereas one patient had incidental finding of Meckel's diverticulum at the time of surgery for pyloric atresia plus he had been operated upon for right-sided pelvioureteric junction obstruction at 1 year of age. All patients underwent laparotomy after stabilization. The two patients presenting late had type 1 pyloric atresia with a pyloric membrane having a central hole in both the patients. So, excision of the membrane with Heineke Mikulicz pyloroplasty was done in both of them. The neonate who presented early had type 2 pyloric atresia and underwent Finney's pyloroplasty.

Per-Oral Pyloromyotomy (POP): An Emerging Application of Submucosal Tunneling for the Treatment of Refractory Gastroparesis

A growing body of literature supports the use of laparoscopic pyloroplasty as a minimally invasive treatment of refractory gastroparesis that has failed conservative measures and for benign gastric outlet obstruction. Endoscopic pyloric dilation, stent placement, and Botox have been described for similar indications, but often with transient or mixed results. Per-oral pyloromyotomy has recently been proposed as an endoscopic alternative to surgical pyloroplasty or pylormyotomy because it is less invasive by its nature and potentially more durable than current endoscopic treatments.

Esophagogastric anterior wall anastomosis combined with pyloroplasty after surgery for early cardia cancer

AIM: To compare the effect of two different digestive tract reconstruction procedures after surgery for early cardia cancer on postoperative quality of life.

METHODS: One hundred and five patients who underwent surgery for early cardia cancer were randomly divided into an observation group (esophagogastric anterior wall anastomosis combined with pyloroplasty, 55 cases) and a control group (esophagogastric posterior wall anastomosis combined with lip type embedding, 50 cases). The patients were followed for 6 mo postoperatively. Operation time, hospital stay, postoperative reflux esophagitis, and anastomotic stenosis were compared between the two groups.

RESULTS: Clinical cure was achieved in all patients in the two groups. Operation time and postoperative hospital stay showed no statistically significant difference between the observation group and control group (151.00 min ± 6.03 min vs 149.00 min ± 7.02 min, 16.15 d ± 3.13 d vs 15.27 d ± 3.06 d, P > 0.05). The incidences of reflux esophagitis and anastomotic stenosis were significantly lower in the observation group than in the control group [18.2% (10/55) vs 56.0% (28/50), 1.8% (1/55) vs 22.0% (11/50), P < 0.05].

CONCLUSION: Esophagogastric anterior wall anastomosis combined with pyloroplasty is an ideal digestive tract reconstruction procedure after surgery for early cardia cancer.

Laparoscopic pyloroplasty is a safe and effective first-line surgical therapy for refractory gastroparesis. Surg Endosc. 2016;30:1326-1332. [PMID: 26293794 DOI: 10.1007/s00464-015-4385-5]

INTRODUCTION

Surgical options for symptomatic delayed gastric emptying include gastric stimulator implantation, subtotal gastrectomy, and pyloroplasty. Pyloroplasty has been shown to improve gastric emptying yet is seldom described as a primary treatment for gastroparesis. We present a single-institution experience of laparoscopic Heineke-Mikulicz pyloroplasty (LP) as treatment for gastroparesis.

METHODS AND PROCEDURES

A prospective foregut surgery database was queried for LP over a 5-year period. Charts were reviewed for indications, complications, symptom score, and outcomes. Gastroparesis was defined by (1) abnormal gastric emptying study, (2) endoscopic visualization of retained food after prolonged NPO status, or (3) clinical symptoms suspicious of vagal nerve injury following complex re-operative foregut surgery. Results were analyzed using a paired T test and single-factor ANOVA.

RESULTS

One hundred and seventy-seven LP patients were identified and reviewed. One hundred and five had a concurrent fundoplication for objective reflux. There were no intraoperative complications or conversions to laparotomy. Overall morbidity rate was 6.8% with four return to OR and two confirmed leaks (1.1% leak rate). Average length of stay was 3.5 days, and readmission rate was 7%. Eighty-six percent had improvement in GES with normalization in 77%. Gastric emptying half-time decreased from 175 ± 94 to 91 ± 45 min. Nineteen patients (10.7%) had subsequent surgical interventions: gastric stimulator implantation (12), feeding jejunostomy and/or gastrostomy tube (6), or subtotal gastrectomy (4). Symptom severity scores for nausea, vomiting, bloating, abdominal pain, and early satiety decreased significantly at 3 months.

CONCLUSION

Laparoscopic pyloroplasty improves or normalizes gastric emptying in nearly 90% of gastroparesis patients with very low morbidity. It significantly improves symptoms of nausea, vomiting, bloating, and abdominal pain. Some patients may go on to another surgical treatment for GP, but it remains a safe and less invasive alternative to a subtotal gastrectomy in these clinically challenging patients.

Laparoscopic circular stapled longitudinal extramucosal pyloroplasty: an alternative technique for pyloric disruption

OBJECTIVES

Oesophagectomy with gastric pull-up is the most common surgical procedure for oesophageal cancer. Pyloroplasty may be performed to facilitate stomach emptying, but its role is still controversial. When laparoscopic mobilization of the stomach is performed, conventional extramucosal pyloroplasty may be difficult to carry out; therefore, we describe a new technique for mechanical pyloric disruption.

METHODS

We conceived the laparoscopic longitudinal extramucosal partial section of the anterior pyloric wall using a circular stapler. We performed it in 6 patients undergoing oesophagectomy for cancer, with the laparoscopic abdominal step before thoracotomy.

RESULTS

The procedure was easy and safe and without intraoperative complications in all patients. Postoperative video-oesophagogram showed regular anastomosis and graft emptying.

CONCLUSIONS

Our preliminary experience has led us to conclude that circular stapler longitudinal extramucosal pyloroplasty is an easy, safe and quick procedure that can be performed in laparoscopic surgery. Moreover, it seems to ensure a regular emptying of the graft as standard pyloroplasty does.

Pyloric sphincter therapy: botulinum toxin, stents, and pyloromyotomy

Gastroparesis is a syndrome characterized by delayed gastric emptying with associated symptoms. Gastric emptying is a complex process and pyloric dysfunction may play a key role in select subsets of patients with gastroparesis. Diagnostic tests to measure pyloric physiology are now available and have the potential to be more widely used in clinical practice. Targeted therapies including botulinum toxin, transpyloric stent placement, surgical pyloroplasty and endoscopic pyloromyotomy have been developed. Data are emerging regarding efficacy and durability, but these therapies may play a prominent role in select patients with gastroparesis and pyloric dysfunction.

Surgical Management of Gastric Outlet Obstruction Due to Corrosive Injury

Corrosive gastric injury is common in India due to easily available acids which are ingested mostly for suicide attempt. Resulting gastric outlet strictures need operation in majority of the patients. We review our experience of surgical management of these cases. Thirty-seven consecutive patients over the last 4 years with corrosive gastric strictures were reviewed. Extent of gastric cicatrisation was assessed by endoscopy and barium study. Nutrition was maintained, if necessary by feeding jejunostomy. Early definitive operation was preferred. Outcome of surgery was assessed. Patients presented with vomiting, weight loss, and dysphagia. Twenty patients (54 %) had predominant gastric corrosive injury. The oesophageal stricture in other 17 patients (46 %) could be managed easily by endoscopic dilatation. Prepyloric short gastric stricture was found in 19 patients (51 %). Surgical procedures included stricturoplasty for short strictures and gastrojejunostomy for more extensive distal gastric cicatrisation. Complications included wound infection in six (16 %) patients and pneumonitis in four (11 %) patients. All patients gained weight within 6 to 8 weeks. Management of corrosive gastric injury depends on the extent of gastric involvement, associated oesophageal stricture, and general condition of the patient. Early definitive operation and avoiding gastric resection can give satisfactory outcome.