Gastroparesis by Unknown

Author:Unknown
Language: eng
Format: epub
ISBN: 9783030289294
Publisher: Springer International Publishing

Fig. 5.2Creation of a mucosotomy

Fig. 5.3Creation of a submucosal tunnel

Fig. 5.4Division of the pyloric muscle

Fig. 5.5Use of the TT knife to begin the pyloromyotomy

Fig. 5.6Progressive division of the pyloromyotomy

Fig. 5.7Endoscopic clip closure of the mucosotomy

If used, the endoluminal functional imaging probe, Endoflip , is passed alongside the scope through the pyloric channel under endoscopic visualization by grasping a suture attached to the distal part of the probe using a biopsy forceps [84]. The pyloric ring is identified and traversed under endoscopic visualization. The Endoflip balloon is inflated to 40 or 50 mL for 5 or more seconds. The diameter, cross-sectional area, pressure, distensibility, and compliance can be measured or calculated by the bundled software. Preliminary studies have demonstrated that gastroparetic patients have lower pyloric distensibility at 40 mL than healthy volunteers. This data may be further employed to understand and predict the success or failure of the POP procedure [78, 84].

Overall, the clinical significance of the minor differences, such as anterior versus posterior mucosal entry, partial versus full-thickness pyloromyotomy, suturing versus endoscopic clip closure, or the use of fluoroscopy guidance to identify the pyloric ring, is not yet known [62, 73–76, 79]. The POP appears to produce consistent results in terms of proportion of patients responding to pyloric disruption with an improvement in symptoms and gastric emptying despite the heterogeneity in technique, length of follow-up, and subjective and objective symptomatic assessment.

After the POP procedure, patients were initially admitted overnight and kept nil per os (NPO) until an upper gastrointestinal (UGI) study was performed the following morning with water-soluble contrast. If the study was found to be normal with no signs of a leak, then a clear liquid diet was started. Patients were typically discharged on postoperative day 1 on a clear liquid diet that was steadily advanced to a full liquid diet over a week. At our institution, however, with increased experience in performing the POP procedure, the POP procedure is performed in an outpatient endoscopy suite, and patients are discharged home on the same day without an UGI study . If there is concern for full-thickness perforation or if the patient prefers to be admitted, then they are admitted overnight and may undergo an UGI study. Patients are discharged home with a liquid diet for 2 weeks (anything that can be poured) followed by a soft diet. They are usually followed-up with an in person or virtual visit in 2 weeks. Due to the risk of ulcer formation and bleeding at the mucosotomy site, patients are discharged with a proton pump inhibitor and sucralfate therapy for at least 2 weeks postoperatively [69]. A gastric emptying study is repeated at 2–3 months postoperatively. Various validated scoring systems have been implemented to assess post procedure clinical improvement. These include the Gastroparesis Cardinal Symptoms Index (GCSI), Patient Assessment of Gastrointestinal Symptoms (PAGISYM), and Clinical Patient Grading Assessment Score. Quality of life was also objectively measured using a standardized short form 36 (SF-36) [72, 73]. Clinical improvement has generally been defined as no

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