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

  • Endoluminal Surgery
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Abstract

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.

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References

  1. Stanghellini V, Chan FK, Hasler WL, Malagelada JR, Suzuki H, Tack J, Talley NJ (2016) Gastroduodenal disorders. Gastroenterology 150(6):1380–1392. https://doi.org/10.1053/j.gastro.2016.02.011

    Article  PubMed  Google Scholar 

  2. Liu N, Abell T (2017) Gastroparesis updates on pathogenesis and management. Gut Liver 11(5):579–589

    Article  PubMed  PubMed Central  Google Scholar 

  3. Parckman HP (2015) Idiopathic gastroparesis. Gastroenterol Clin N Am 44(1):59–68

    Article  Google Scholar 

  4. Tack J (2007) The difficult patient with gastroparesis. Best Pract Res Clin Gastroenterol 21(3):379–391

    Article  PubMed  Google Scholar 

  5. Soreide K, Sarr MG, Soreide JA (2006) Pyloroplasty for benign gastric outlet obstruction: indications and techniques. Scan J Surg 95:11–16

    Article  CAS  Google Scholar 

  6. Tsai CH, Liou GJ, Liu CL, Pan JS, Lee JJ, Cheng SP, Liu TP (2012) Surgical management of benign gastric outlet obstruction in the elderly. Hepatogastroenterology 59(117):1643–1646

    PubMed  Google Scholar 

  7. Miller A, Schwaitzber S (2014) Surgical and endoscopic treatment options for benign and malignat gastric outlet obstruction. Curr Surg Rep 2:48

    Article  Google Scholar 

  8. Kashab MA, Stein E, Clarke JO, Saxena P, Kumbhari V, Chander Roland B, Kalloo AN, Stavropoulos S, Pasricha P, Inoue H (2013) Gastric Peroral endoscopic myotomy for refractory gastroparesis: first human endoscopic pyloromyotomy. Gastrointest Endosc 78(5):764–768. https://doi.org/10.1016/j.gie.2013.07.019

    Article  Google Scholar 

  9. Shada AL, Dunst CM, Pescarus R, Speer EA, Cassera M, Reavis KM, Swanstrom LL (2016) Laparoscopic pyloroplasty is a safe and effective first-line surgical therapy for refractory gastroparesis. Surg Endosc 30(4):1326–1332. https://doi.org/10.1007/s00464-015-4385-5

    Article  PubMed  Google Scholar 

  10. Soares RV, Molos M, Donepudi P, Kong SH, Swanstrom LL (2016) Transgastric hybrid surgery for the flexible endoscopist: early experience with the TAGSS system. Gastrointest Endosc 84(5):852–853. https://doi.org/10.1016/j.gie.2016.05.033

    Article  PubMed  Google Scholar 

  11. Chao HC (2016) Update on endoscopic management of gastric outlet obstruction in children. World J Gastrointest Endosc 8(18):635–645

    Article  PubMed  PubMed Central  Google Scholar 

  12. Borrazzo EC (2013) Surgical management of gastroparesis: gastrostomy/jejunostomy tubes, gastrectomy, pyloroplasty, gastric electrical stimulation. J Gastrointest Surg 17(9):1559–1561

    Article  PubMed  Google Scholar 

  13. Sarosiek I, Davis B, Eichler E, McCallum RW (2015) Surgical approach to treatment of gastroparesis: gastric electrical stimulation, pyloroplasty, total gastrectomy and enteral feeding tubes. Gastroenterol Clin N Am 44(1):151–167

    Article  Google Scholar 

  14. Hibbard ML, Dunst CM, Swanström LL (2011) Laparoscopic and endoscopic pyloroplasty for gastroparesis results in sustained symptom improvement. J Gastrointest Surg 15(9):1513–1519

    Article  PubMed  Google Scholar 

  15. Toro JP, Lytle NW, Patel AD, David SS Jr, Christie JA, Waring JP, Sweeney JF, Lin E (2014) Efficacy of laparoscopic pyloroplasty for the treatment of gastroparesis. J Am Coll Surg 218(4):652–660. https://doi.org/10.1016/j.jamcollsurg.2013.12.024

    Article  PubMed  Google Scholar 

  16. McCarty TR, Rustagi T (2015) Endoscopic treatment of gastroparesis. World J Gastroenterol 21(22):6842–6849

    Article  PubMed  PubMed Central  Google Scholar 

  17. Shlomovitz E, Pescarus R, Cassera MA, Sharata AM, Reavis KM, Dunst CM, Swanstrom LL (2015) Early experience with per-oral endoscopic pyloromyotomy (POP). Surg Endosc 29(3):543–551. https://doi.org/10.1007/s00464-014-3720-6

    Article  PubMed  Google Scholar 

  18. Swanström LL, Lebaras C (2016) Per-oral pyloromyotomy (POP) An emerging application of submucosal tunneling for the treatment of refractory gastroparesis. Gastrointest Endoscopy Clin N Am 26(2):257–270

    Article  Google Scholar 

  19. Kim HH, Uedo N. Hybrid NOTES (2016) Combined laparo-endoscopic full-thickness resection techniques. Gastrointest Endoscopy Clin N Am 26:335–373. https://doi.org/10.1016/j.giec.2015.12.011

    Article  Google Scholar 

  20. Ntourakis D, Mavrogenis G (2015) Cooperative laparoscopic endoscopic and hybrid laparoscopic surgery for upper gastrointestinal tumors: current status. World J Gastroenterol 21(3):12482–12497

    Article  PubMed  PubMed Central  Google Scholar 

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Acknowledgements

The authors are grateful to Sophie Pernot and David Bass for their contributions to the successful implementation of this study.

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Correspondence to Lee Swanstrom.

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Disclosures

Drs. Cristians Gonzalez, Jung-Myun Kwak, Federico Davrieux, Ryohei Watanabe, Jacques Marescaux and Lee Swanstrom, have no conflicts of interest or financial ties to disclose.

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Gonzalez, C., Kwak, JM., Davrieux, F. et al. Hybrid endoluminal stapled pyloroplasty: an alternative treatment option for gastric outlet obstruction syndrome. Surg Endosc 33, 303–308 (2019). https://doi.org/10.1007/s00464-018-6493-5

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  • DOI: https://doi.org/10.1007/s00464-018-6493-5

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