Post written by Alexander J. Podboy, MD, from the University of Virginia, Charlottesville, Virginia, USA.

Gastroparesis is a debilitating condition that leads to poor quality of life. Although gastric peroral endoscopic myotomy (G-POEM) has emerged as a novel treatment, its success rates are variable, and options for patients with refractory symptoms remain limited.

This video case introduces a modified procedure, “the open accordion,” which uses modified endoscopic sleeve gastroplasty (ESG) to tubularize the stomach as a potential solution for patients with gastroparesis who fail G-POEM.

Two patients with post-transplant gastroparesis who failed multiple treatments, including dietary changes, prokinetic medications, botulinum toxin, and G-POEM, elected to undergo modified ESG for refractory symptoms.

The modified ESG technique involving gastric tubularization using a double-channel endoscope and an over-the-scope suturing device was performed with a goal to promote tubularization using a modified alternating “U” and an “I” suture pattern. Goal gastric volume restriction was <50%, avoiding excessive restriction to prevent weight loss. 

The final “I” suture was elongated into a “J” shape to exclude the gastric fundus without direct fundal suturing to limit morbidity and minimize alterations in gastric fundal hormonal secretion. The procedure was completed with no significant adverse events, and both patients were managed with a structured postoperative diet and nutritional support.

Both patients demonstrated significant improvements. Gastroparesis cardinal symptom index scores improved by a mean of 69%, with the greatest reduction in postprandial fullness. Gastric emptying scintigraphy showed notable improvements in gastric retention at 1, 2, and 4 hours, with reductions of 17%, 23% to 15.5%, and 27% to 29.7%, respectively. No weight loss was noted for either patient at 3-month follow-up.

To our knowledge, this is the first case series to report the use of modified ESG for refractory gastroparesis (open accordion) after failed G-POEM. The procedure resulted in significant improvements in symptoms and gastric emptying without adverse effects on weight. The modified ESG approach, with limited gastric volume restriction and no direct fundal suturing, appears to be a promising, less-invasive alternative to surgical treatments. Larger studies are needed to confirm these findings and explore long-term outcomes.

Therapies for medically refractory gastroparesis are limited. This case highlights the potential of modified ESG as an effective treatment for medically refractory gastroparesis, offering an alternative to more-invasive surgical options.

Use of modified ESG to promote gastric tubularization after failed G-POEM provides a promising, minimally invasive option for treatment of refractory gastroparesis. Endoscopists can consider this approach when standard therapies have been ineffective, especially in patients who are not surgical candidates.

Volume restriction noted following modified endoscopic sleeve gastroplasty for the treatment of refractory gastroparesis.

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