Post written by Danny Issa, MD, from the Division of Gastroenterology and Hepatology, Weill Cornell Medicine/New York, Presbyterian Hospital, New York, New York, USA.

We performed gastric peroral endoscopic myotomy (GPOEM) using a lesser curve approach on 3patients with severe gastroparesis refractory to medical therapy. Two of the patients had undergone prior GPOEM with the traditional greater curve approach in the past and developed a recurrence of symptoms. All patients experienced classic symptomology of gastroparesis and had abnormal gastric emptying study. The mean gastroparesis cardinal symptom index (GCSI) prior to GPOEM was 2.7. The procedure was performed under general anesthesia with the patient in the supine position and using a standard gastroscope fitted with a clear attachment cap. A submucosal injection was made with normal saline with methylene blue approximately 3 cm proximal to the pylorus along the antral lesser curve. This was followed by a transverse incision to create an entry point to the submucosal space. A Dual or IT2 knife (Olympus Corporation, Center Valley PA) was used to enable the incision and subsequently dissect the submucosal fibers. Visible vessels and bleeding were treated with coagulation (soft coag effect 2; Erbe, Marietta GA). Dissection was continued until the pyloric ring was exposed. After confirming the position, a full-thickness myotomy of the pylorus was performed using IT2 knife. The mucosal entry was then closed using endoclips. The average procedure time was 48 ±12 minutes. No immediate or late complications occurred, and all patients were discharged home in good conditions. The mean GCSI post-GPOEM was 0.7, and all patients were asymptomatic on a 6-month follow up.

The pyloric ring exposure was excellent using the lesser curve GPOEM. This approach provided a better angle for dissecting the hypertrophic muscle layer and relatively short tunnel and short procedure duration.

GPOEM via the lesser curve is technically feasible. This novel approach can be offered as a primary or salvage treatment for persistent gastroparesis after a failed initial greater curve myotomy.

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