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DOI: 10.1055/s-0034-1377599
Endoscopic pyloromyotomy for postesophagectomy gastric outlet obstruction
Publication History
Publication Date:
04 August 2014 (online)
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Postesophagectomy gastric outlet obstruction occurs in 20 % – 30 % of patients who undergo esophagectomy and is associated with significant morbidity and delayed recovery [1]. Recently, endoscopic pyloromyotomy, also called gastric peroral endoscopic myotomy (POEM), has been reported, in pigs and in a patient with refractory diabetic gastroparesis [2] [3]. We report a case of postesophagectomy delayed gastric emptying that was successfully treated with endoscopic pyloromyotomy.
A 54-year-old woman was referred to the gastroenterology department because of vomiting 2 weeks after esophagectomy with gastric pull-up for esophageal squamous cell carcinoma. Esophagography revealed marked delay in passage of contrast through the pylorus and the gastroscope could not be passed through the pylorus ([Fig. 1]). On postoperative day 17, endoscopic balloon dilation was performed and it was possible to pass the scope through the pylorus. However, 3 weeks later (postoperative day 39), she visited our clinic because of recurrent vomiting. Esophagogastroduodenoscopy (EGD) revealed significant food stasis in the pulled-up stomach and again the endoscope could not be passed through the pylorus.
Fig. 1 A 54-year-old woman presented with vomiting 2 weeks after esophagectomy with gastric pull-up. a Esophagography revealed marked delay in passage of contrast through the pylorus. b Fluid retention was noted on esophagogastroduodenoscopy (EGD) and the scope could not be passed through the pylorus.
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Endoscopic pyloromyotomy was performed with the patient under conscious sedation. Saline solution mixed with indigo carmine was injected on the greater curvature 5 cm proximal to the pylorus. A 1.5-cm mucosal incision was made ([Fig. 2]) using a DualKnife (KD-650L; Olympus, Tokyo, Japan). Submucosal tunneling towards the pylorus was done using Endocut I (E2-D2-I3) (VIO 300D; ERBE, Tübingen, Germany) and Swift Coag modes (E4-40 W). When the scope reached the pylorus, selective circular and/or oblique myotomy was done. The outer longitudinal muscle was preserved. The mucosal entry was then closed using four endoscopic clips ([Video 1]).
Fig. 2 Endoscopic pyloromyotomy: a creation of mucosal entry; b submucosal tunneling; c pyloromyotomy; d closure of mucosal entry.
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Quality:
On the following day, fluoroscopy showed significant improvement in passage of contrast ([Fig. 3]) and the gastroscope (GIF-H260; Olympus) could pass smoothly through the pylorus. The patient was started on a liquid diet and was discharged the next day. She remains well 10 weeks after the procedure and appropriately tolerates a general diet.
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References
- 1 Lanuti M, de Delva PE, Wright CD et al. Post-esophagectomy gastric outlet obstruction: role of pyloromyotomy and management with endoscopic pyloric dilatation. Eur J Cardiothorac Surg 2007; 31: 149-153
- 2 Kawai M, Peretta S, Burckhardt O et al. Endoscopic pyloromyotomy: a new concept of minimally invasive surgery for pyloric stenosis. Endoscopy 2012; 44: 169-173
- 3 Khashab MA, Stein E, Clarke JO et al. Gastric peroral endoscopic myotomy for refractory gastroparesis: first human endoscopic pyloromyotomy (with video). Gastrointest Endosc 2013; 78: 764-768