Gastric per-oral endoscopic myotomy: Current status and future directions

Table 1 Depicts pre-clinical demographic and clinical data and post-operative changes to symptoms and gastric emptying

Article	Shlomovitz et al[25], 2014	Gonzalez et al[26], 2017	Kahaleh et al[27], 2018	Rodriguez et al[28], 2017	Rodriguez et al[29], 2018	Malik et al[30], 2018	Jacques et al[31], 2017	Dacha et al[32], 2017	Mekaroonkamol et al[33], 2018	Khashab et al[34], 2017
n	7	29	33	47	100	13	20	16	30	30
Female (%)	100	65.50	66	78.70	85.00	53.58	—	81.25	86.70	57
Age (mean)	51	52.8	52	43.7	45	45.7	—	44.76	47	47
Previous gastric stim	—	4 (13.8%)	2 (6%)	16 (34.0%)	20 (20%)	3 (23%)	0	4 (25%)	4 (13.3%)	0
Previous botox treatment	—	1 (3%)	4 (12%)	28 (59.6%)	46 (46%)	11 (84.6%)	2 (10%)	0	1 (3%)	12 (40%)
Pre GES 4 h (mean %)	21	40 ± 34	45	37.2 ± 25.1	39 ± 26.5	49 ± 24	57	62.5	63.0 ± 25.5	37
Pre GCSI		3.3 ± 0.9		4.61	3.8 ± 0.86	2.2 ± 0.8	3.5	3.41	3.5 ± 0.6
Gastroparesis: Idiopathic	4	15	12	27	56	4	4	5	12	7
Gastroparesis: Diabetes	0	7	7	12	21	1	10	9	12	11
Gastroparesis: Post-surgical	2	5	12	8	19	8	1	1	5	12
Gastroparesis: Scleroderma	0	2	2	—	—	—	1	0	0	0
Total of major postoperative complications	4/7	5/29	1/33	0/47	10/100	1/13	3/20	0/16	1	2/30
Post GES Residual 4 hours	4%	28 ± 45	17% ± 17	20.4 ± 26.1	16.3 ± 21.4	33 ± 28	15	25.4	22.2 ± 20.5	17% ± 16
Symptom improvement	85.70%	69%	86%	—	—	73%	90%	81%	76.70%	86%
How defined improvement	Clinical improvement	Decrease in GCSI	Clinical improvement1	Not defined	Not defined	CPGAS score	GCSI decrease by 0.75	Decrease in GCSI	Decrease in GCSI2	Clinical improvement
Length of follow up (mo)	6.5	6	6	3	3	3	3	12	6-18	6
Timing of F/u GES in days	84	56	—	90	90	84	84	56	42-56	81-105
GES improvement	4/5 (90%)	23/29 (79.3%)	—	—	78% α	4/6 (66.7%)	19/20 (95%)	12/12 (100%)	78.3%α	14/17, 82.3%
Normalization of GES	0/5	16/29	4/6	—	57% α	0	6/20	9/12	47.8%α	8/17

¹And lack of hospitalizations;

²Defined as 1 averaged point in total Gastroparesis Cardinal Symptom Index with more than 25% decrease in 2 subscales;

^αTotal number not provided. GCSI: Gastroparesis Cardinal Symptom Index; GES: Gastric Emptying Study; CPGAS: Clinical Patient Grading Assessment Scale.

Table 2 Demonstrates procedural data including equipment used and post-operative practice reported across the studies

Article	Shlomovitz et al[25], 2014	Gonzalez et al[26], 2017	Kahaleh et al[27], 2018	Rodriguez et al[28], 2017	Rodriguez et al[29], 2018	Malik et al[30], 2018	Jacques et al[31], 2017	Dacha et al[32], 2017	Mekaroonkamol et al[33], 2018	Khashab et al[34], 2017
n	7	29	33	47	100	13	20	16	30	30
Procedure length (min)	90-1201	47 ± 22	77.6 (37-255)	41.2 ± 28.5	33.8 ± 21.6	119 ± 23	56.5	49.7 ± 22.1	48.3 ± 16.5	72 ± 42
Length of stay (mean)	2.3	—	5.4 (1-14)	1.09 ± 0.6	1.3 ± 1.05	2.5 ± 1.4 d	3.75	2.46	2.4 ± 1.0	—
Pre ABX	Yes, IV	Yes, IV	Gentamicin wash	None	None	Gentamicin wash	None	Yes, IV	Yes	Post-Op
Site of mucosotomy (cm proximal to pylorus)	5	5	5-6	5	4	5	4-5	5	5-7	5
Mucosal entry location	greater curvature in 31, 2 patients lesser curvature.	Greater curvature 19, anterior wall 9, posterior wall 2	greater curvature	—	95 lesser curvature, 4 greater, 1 posterior	greater curvature	greater curvature	lesser curvature	—	—
Lift Solution	5-10 mL 1: 10000 Epi	—	5 mL methylene blue and 500 saline mixture	methylene blue6	methylene blue	Not used	glycerol	5 mL methylene blue and 500 saline mixture	—	saline and 0.25% indigo carmine solution or methylene blue solution2
Size of mucsoal incision (cm)	1-2	—	2	2	—	—	—	2	3-4	1.5-2
Knife Used	T Knife	Triangle knife	Hybrid knife or IT2	Triangular knife	triangle tip knife	I-Type Hybrid knife	T-Type for initial incision, Hybrid knife for tunnel, Hook Knife for myotomy	Hook Knife or I-type knife	I hybrid knife	Triangular tip knife
Size of myotomy mean (cm)		2	3.34 (2-6)	—	—	3.5 ± 0.8	—	3.94	2-3	—
Upper GI series	—	—	—	POD 1	POD 1	POD 1-2	—	POD 1	POD 1	POD 1
Use of PPI	BID PPI for 6 wk	BID PPI for 4 wk	—	PPI BID for 4 wk w/Sucralfate	BID PPI and QID sucralfate for at least 2 wk	—	—	—	BID for 8 wk
Antibiotics on discharge	—	—	—	—	—	—	—	5 d oral Abx	—	IV Abx following procedure
Dietary restrictions	Clear liquid immediately, pureed/soft diet for 2 wk,	observed for 1 d NPO, then advanced to clears, observed for 5 d and sent home on	Clear liquid diet 2-3 d, advanced to gastroparetic diet	advanced to clears with liquid diet for 2 wk	liquid diet for 2-4 wk	Clear liquid diet, advance as tolerated	Liquid diet day after procedure	advance to liquid after upper GI and ADAT	clear liquid and advanced diet over 4 wk course	liquid diet started then advanced to soft then to gastroparetic diet
Total of major post operative complications	4/7	5/29	1/33	0/47	10/100	1/13	3/20	0/16	1	2/30

¹Time to myotomy;

²No specified amount; GCSI: Gastroparesis Cardinal Symptom Index; GES: Gastric Emptying Study; CPGAS: Clinical Patient Grading Assessment Scale; G-POEM: Per-oral endoscopic pyloromyotomy; BID Twice daily; PPI: Proton Pump Inhibitor; ABX: Antibiotics; IV: Intravenous; POD: Post operative day; NPO: Nil per os; ADAT: Advance diet as tolerated.