P3724 - Pyloromyotomy Performed Through Gastrostomy: Demonstration of Feasibility

Dawid Nowak, MD¹, Dhruv Patel, DO², Gabriel Melki, MD¹, Yana Cavanagh, MD^2
1St. Joseph's University Medical Center, Paterson, NJ; ²St. Joseph's University Medical Center, Paterson, NJ

Introduction: Gastroparesis is a progressive disease that significantly impacts a patient's quality of life. Although the pathogenesis is multifactorial, pylorospasm is believed to have a major underlying role. G-POEM is an endoscopic therapeutic modality for treatment of refractory gastroparesis.

Case Description/Methods: A 17 y/o M with a PMH of Lennox-Gastaut syndrome and gastroparesis who presented with sepsis. Upper GI series revealed reflux and an episode of resultant aspiration. The patient underwent exploratory laparotomy to revise a previous Nissen fundoplication, however due to the patient's dense adhesions the procedure was unsuccessful. Concomitantly, the patient underwent esophagogastric dissociation, a spit fistula, and replacement of his G-tube, to prevent further episodes of aspiration. Unfortunately, large residuals were noted after G-tube feedings. IR guided G-tube conversion to GJ-tube was unsuccessfully attempted due to the patients complex anatomy and contractions.



The decision was made to pursue endoscopic GJ tube placement with pyloromyotomy through his existing gastrostomy. The procedure was performed by dilating the gastrostomy orifice with Savary dilators and a small skin incision - to facilitate the dilation. Following dilation, a 12 mm diameter trocar was passed under direct visualization through the stoma. The pylorus was noted to have moderate to severe stenosis with an underlying anatomic angulation and resultant gastric antral folds overlying the pylorus compounding the gastric outlet obstruction. Mucosotomy followed by pyloromyotomy was performed along the lesser curvature of the stomach. Upon successful completion of the myotomy, a GJ-tube was placed. Subsequently, our patient had an upper GI series and confirmed absence of a leak and the patient was able to tolerate tube feeds up to 80mL/hr for the remainder of the admission.

Discussion: This case demonstrated the feasibility of performing pyloromyotomy through gastrostomy stomas with successful management of refractory gastroparesis. This approach is a viable alternative in cases where the traditional per-oral approach is not possible due to anatomical variance.



Disclosures:


Dawid Nowak, MD¹, Dhruv Patel, DO², Gabriel Melki, MD¹, Yana Cavanagh, MD². P3724 - Pyloromyotomy Performed Through Gastrostomy: Demonstration of Feasibility, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.