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World J Gastrointest Surg. Jan 27, 2022; 14(1): 12-23
Published online Jan 27, 2022. doi: 10.4240/wjgs.v14.i1.12
Gastric per-oral endoscopic myotomy: Indications, technique, results and comparison with surgical approach
Maria Chiara Verga, Stefano Mazza, Francesco Azzolini, Fabrizio Cereatti, Clara Benedetta Conti, Andrea Drago, Sara Soro, Biagio Elvo, Roberto Grassia
Maria Chiara Verga, Stefano Mazza, Fabrizio Cereatti, Andrea Drago, Sara Soro, Biagio Elvo, Roberto Grassia, Gastroenterology and Digestive Endoscopy Unit, ASST Cremona, Cremona 26100, Italy
Francesco Azzolini, Gastroenterology and Digestive Endoscopy Unit, Ospedale San Raffaele IRCCS, Milano 20132, Italy
Clara Benedetta Conti, Digestive and Interventional Endoscopy Unit, ASST Monza, Monza 20800, Italy
Author contributions: All authors contributed to literature search and data collect; Verga MC, Azzolini F and Cereatti F wrote the paper; Mazza S, Conti CB, Drago A, Soro S, Elvo B and Grassia R critically revised the paper and contributed to the final version of the manuscript.
Conflict-of-interest statement: The authors declare that they have no conflict of interest.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Maria Chiara Verga, MD, Doctor, Gastroenterology and Digestive Endoscopy Unit, ASST Cremona, Viale Concordia, 1, Cremona 26100, Italy.
Received: May 2, 2021
Peer-review started: May 2, 2021
First decision: June 27, 2021
Revised: July 20, 2021
Accepted: December 22, 2021
Article in press: December 22, 2021
Published online: January 27, 2022

Gastroparesis is a chronic disease of the stomach that causes a delayed gastric emptying, without the presence of a stenosis. For 30 years the authors identified pylorospasm as one of the most important pathophysiological mechanisms determining gastroparesis. Studies with EndoFLIP, a device that assesses pyloric distensibility, increased the knowledge about pylorospasm. Based on this data, several pyloric-targeted therapies were developed to treat refractory gastroparesis: Surgical pyloroplasty and endoscopic approach, such as pyloric injection of botulinum and pyloric stenting. Notwithstanding, the success of most of these techniques is still not complete. In 2013, the first human gastric per-oral endoscopic myotomy (GPOEM) was performed. It was inspired by the POEM technique, with a similar dissection method, that allows pyloromyotomy. Therapeutical results of GPOEM are similar to surgical approach in term of clinical success, adverse events and post-surgical pain. In the last 8 years GPOEM has gained the attention of the scientific community, as a minimally invasive technique with high rate of clinical success, quickly prevailing as a promising therapy for gastroparesis. Not surprisingly, in referral centers, its technical success rate is 100%. One of the main goals of recent studies is to identify those patients that will respond better to the therapies targeted on pylorus and to choose the better approach for each patient.

Keywords: Gastric per-oral endoscopic myotomy, Pyloroplasty, Gastroparesis, EndoFLIP, Pyloromyotomy, Gastroparesis cardinal symptom index

Core Tip: Many studies tried to identify the factors that may predict the response to pyloric targeted therapies in gastroparesis according to etiology, prevalent symptoms, antroduodenal manometric study and EndoFLIP. Unfortunately, it is still difficult to reach an accurate determination of the optimal candidates for each treatment. Currently, surgical and endoscopic approach has been compared in term of safety and the results seem encouraging for endoscopic method. In this review we summarize indications, side effects and outcome of gastric per-oral endoscopic myotomy compared to surgical pyloroplasty.