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• W2078118712 abstract "Pyloroplasty may be an effective treatment whether gastric emptying is secondary to pyloric dysfunction (spasm, stricture) or gastroparesis (postvagotomy, diabetic gastropathy, postviral, or idiopathic).Replacing open surgical procedures with less invasive alternatives has been a hallmark development of the last 3 decades. This has been made possible by developments in technology—especially the introduction of video-endoscopy, both flexible and rigid (laparoscopy). GI surgical procedures such as sphincteroplasty, feeding gastrostomy, pseudocyst drainage, and others are well performed when a flexible endoscope is used. Likewise, laparoscopy has replaced open cholecystectomy, fundoplications, appendectomy, and, most recently, colectomy, resulting in substantial benefit to patients. Until recently, there was a sharp divide between the world of surgical and flexible endoscopy, which was defined by the wall of the GI tract. There is, however, increasing evidence that this separation is about to fall as technology enables flexible endoscopy to safely open and close the wall of the intestinal tract. Few gastroenterologists or GI surgeons are not aware of the potential advent of NOTES (natural orifice transluminal endoscopic surgery), even though it remains a laboratory-based endeavor with only theoretical clinical application and totally unknown patient benefit.1Rattner D. Kalloo A.N. ASGE/SAGES Working Group ASGE/SAGES working group on Natural Orifice Transluminal Endoscopy.Gastrointest Endosc. 2006; 63: 199-203Abstract Full Text Full Text PDF PubMed Scopus (24) Google ScholarThere is currently a massive effort to develop enabling technology for NOTES, such as tissue approximation, and access devices, as well as to define basic issues, such as safe access, infection control, physiologic impacts, and basic procedural techniques. If one accepts that the required technology will eventually be created and that these basic questions can be answered, the key question that remains is which will be the first widely applicable NOTES procedure. To date, there have been advocates of cholecystectomy, appendectomy, staging peritoneoscopy, tubal ligation, gastrojejunostomy, hernia repair, adrenalectomy, and others as the best starting point. Starting with these procedures, however, presents some definite concerns regarding the unproven patient benefit and unknown risk profile. In addition, these would be relatively complex procedures involving exposure, retraction, dissection, hemostasis, specimen retrieval, as well as secure closure of the gastrotomy or colotomy. This makes the possibility of an endoluminal pyloroplasty as an early NOTES procedure an intriguing one—avoiding as it does issues of intraperitoneal navigation, retraction, retroflexed orientation, and specimen removal. Because a gastrotomy is required for the procedure whether it is performed openly, laparoscopically, or endoluminally, there is little added patient risk, as long as the closure is secure. Park et al2Park P.-O. Bergström M. Ikeda K. et al.Endoscopic pyloroplasty with full-thickness transgastric and transduodenal myotomy with sutured closure.Gastrointest Endosc. 2007; 66: 116-120Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar describe a method of endoluminal pyloric division using a standard needle knife cautery and a classic transverse closure with full-thickness T fasteners.2Park P.-O. Bergström M. Ikeda K. et al.Endoscopic pyloroplasty with full-thickness transgastric and transduodenal myotomy with sutured closure.Gastrointest Endosc. 2007; 66: 116-120Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar As pointed out by the authors, some of their procedures were unsuccessful, some because of the porcine anatomy and others due to technical problems with achieving a full thickness incision, a patent lumen, or a leak-proof closure. The potential, however, for replicating a traditional pyloroplasty in human patients is easily perceived.Not addressed in the article by Park et al2Park P.-O. Bergström M. Ikeda K. et al.Endoscopic pyloroplasty with full-thickness transgastric and transduodenal myotomy with sutured closure.Gastrointest Endosc. 2007; 66: 116-120Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar are potential clinical applications of an endoluminal pyloroplasty. Pyloroplasty was originally described independently by Heineke in 1886 and von Mikulicz in 1887 as a treatment for pyloric obstruction due to complications of peptic disease. It subsequently came into very common use in the early decades of the 20th century as an adjunct to truncal or proximal vagotomy for treatment of peptic ulcer disease.3Randolph J.G. Y-U advancement pyloroplasty.Ann Surg. 1975; 181: 586-590Crossref PubMed Scopus (10) Google Scholar However, since ulcer disease has faded from the modern surgical scene, the use of pyloroplasty has as well. The classic pyloroplasty has more recently—and somewhat controversially—been advocated by some pediatric surgeons as an adjunct to fundoplication in refluxing and vomiting neurologically impaired children, who often have an additional component of gastroparesis.4Fonkalsrud E.W. Ament M.E. Vargas R. Gastric antroplasty for the treatment of delayed gastric emptying and gastroesophageal reflux in children.Am J Surg. 1992; 164: 327-331Abstract Full Text PDF PubMed Scopus (38) Google Scholar As obesity, diabetes, and other behaviors detrimental to foregut function exponentially increase in the population, adult gastroparetics, whether diabetic, postviral, postsurgical, or idiopathic, are increasingly seen in gastroenterology and GI surgical practices. This has led many surgeons to borrow from the pediatric surgery experience and use a pyloroplasty with a fundoplication for GERD associated with gastroparesis and as a sole procedure for patients with isolated gastroparesis who fail to respond to medical management and who do not qualify for new treatments such as the implantable gastric stimulator.5Salky B. Laparoscopic drainage procedures.Semmin Lapaosc Surg. 1999; 6: 224-228PubMed Google Scholar, 6Farrell T.M. Richardson W.S. Halker R. et al.Nissen fundoplication improves gastric motility in patients with delayed gastric emptying.Surg Endosc. 2001; 15: 271-274Crossref PubMed Scopus (46) Google Scholar Although there is very little literature to support the efficacy of this approach, evidence shows pyloroplasty to be an effective treatment whether gastric emptying is secondary to pyloric dysfunction (spasm, stricture) or gastroparesis (postvagotomy, diabetic gastropathy, postviral, or idiopathic) (Table 1).Table 1Improvement in gastric emptying times (by radionucleide emptying studies) in patients with gastroparesis after laparoscopic Heineke-Mikulicz pyloroplastyPatients123456GES preop t ½ in min130> 120285> 12090Very delayedGES postop t ½ in min37 (16 ms)59 (2 ms)35 (8 ms)54 (8 ms)N/AN/AClinical improvement80%-90%60%-70%60%-70%70%-80%0%80%-90%GES, Gastric Emptying Study.Data from Ziad E, Abouezzi W, Melvin WS, et al. Funtional and symptomatic improvement in patients with diabetic gastroparesis following pyloroplasty. Abstract DDW 1998;abstract #970. Open table in a new tab Patients with severe gastroparesis are increasingly encountered in gastroenterology and GI surgery practices, and it can be very difficult and frustrating to treat them effectively. The ability to perform an effective and incisionless endoluminal procedure would be a true advance for these unfortunate patients. I believe we will see this come to clinical reality in the not-too-distant future, and it may well prove to be the first step into the future of transenteric endoscopic surgery. Pyloroplasty may be an effective treatment whether gastric emptying is secondary to pyloric dysfunction (spasm, stricture) or gastroparesis (postvagotomy, diabetic gastropathy, postviral, or idiopathic).Replacing open surgical procedures with less invasive alternatives has been a hallmark development of the last 3 decades. This has been made possible by developments in technology—especially the introduction of video-endoscopy, both flexible and rigid (laparoscopy). GI surgical procedures such as sphincteroplasty, feeding gastrostomy, pseudocyst drainage, and others are well performed when a flexible endoscope is used. Likewise, laparoscopy has replaced open cholecystectomy, fundoplications, appendectomy, and, most recently, colectomy, resulting in substantial benefit to patients. Until recently, there was a sharp divide between the world of surgical and flexible endoscopy, which was defined by the wall of the GI tract. There is, however, increasing evidence that this separation is about to fall as technology enables flexible endoscopy to safely open and close the wall of the intestinal tract. Few gastroenterologists or GI surgeons are not aware of the potential advent of NOTES (natural orifice transluminal endoscopic surgery), even though it remains a laboratory-based endeavor with only theoretical clinical application and totally unknown patient benefit.1Rattner D. Kalloo A.N. ASGE/SAGES Working Group ASGE/SAGES working group on Natural Orifice Transluminal Endoscopy.Gastrointest Endosc. 2006; 63: 199-203Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar Pyloroplasty may be an effective treatment whether gastric emptying is secondary to pyloric dysfunction (spasm, stricture) or gastroparesis (postvagotomy, diabetic gastropathy, postviral, or idiopathic). Pyloroplasty may be an effective treatment whether gastric emptying is secondary to pyloric dysfunction (spasm, stricture) or gastroparesis (postvagotomy, diabetic gastropathy, postviral, or idiopathic). There is currently a massive effort to develop enabling technology for NOTES, such as tissue approximation, and access devices, as well as to define basic issues, such as safe access, infection control, physiologic impacts, and basic procedural techniques. If one accepts that the required technology will eventually be created and that these basic questions can be answered, the key question that remains is which will be the first widely applicable NOTES procedure. To date, there have been advocates of cholecystectomy, appendectomy, staging peritoneoscopy, tubal ligation, gastrojejunostomy, hernia repair, adrenalectomy, and others as the best starting point. Starting with these procedures, however, presents some definite concerns regarding the unproven patient benefit and unknown risk profile. In addition, these would be relatively complex procedures involving exposure, retraction, dissection, hemostasis, specimen retrieval, as well as secure closure of the gastrotomy or colotomy. This makes the possibility of an endoluminal pyloroplasty as an early NOTES procedure an intriguing one—avoiding as it does issues of intraperitoneal navigation, retraction, retroflexed orientation, and specimen removal. Because a gastrotomy is required for the procedure whether it is performed openly, laparoscopically, or endoluminally, there is little added patient risk, as long as the closure is secure. Park et al2Park P.-O. Bergström M. Ikeda K. et al.Endoscopic pyloroplasty with full-thickness transgastric and transduodenal myotomy with sutured closure.Gastrointest Endosc. 2007; 66: 116-120Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar describe a method of endoluminal pyloric division using a standard needle knife cautery and a classic transverse closure with full-thickness T fasteners.2Park P.-O. Bergström M. Ikeda K. et al.Endoscopic pyloroplasty with full-thickness transgastric and transduodenal myotomy with sutured closure.Gastrointest Endosc. 2007; 66: 116-120Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar As pointed out by the authors, some of their procedures were unsuccessful, some because of the porcine anatomy and others due to technical problems with achieving a full thickness incision, a patent lumen, or a leak-proof closure. The potential, however, for replicating a traditional pyloroplasty in human patients is easily perceived. Not addressed in the article by Park et al2Park P.-O. Bergström M. Ikeda K. et al.Endoscopic pyloroplasty with full-thickness transgastric and transduodenal myotomy with sutured closure.Gastrointest Endosc. 2007; 66: 116-120Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar are potential clinical applications of an endoluminal pyloroplasty. Pyloroplasty was originally described independently by Heineke in 1886 and von Mikulicz in 1887 as a treatment for pyloric obstruction due to complications of peptic disease. It subsequently came into very common use in the early decades of the 20th century as an adjunct to truncal or proximal vagotomy for treatment of peptic ulcer disease.3Randolph J.G. Y-U advancement pyloroplasty.Ann Surg. 1975; 181: 586-590Crossref PubMed Scopus (10) Google Scholar However, since ulcer disease has faded from the modern surgical scene, the use of pyloroplasty has as well. The classic pyloroplasty has more recently—and somewhat controversially—been advocated by some pediatric surgeons as an adjunct to fundoplication in refluxing and vomiting neurologically impaired children, who often have an additional component of gastroparesis.4Fonkalsrud E.W. Ament M.E. Vargas R. Gastric antroplasty for the treatment of delayed gastric emptying and gastroesophageal reflux in children.Am J Surg. 1992; 164: 327-331Abstract Full Text PDF PubMed Scopus (38) Google Scholar As obesity, diabetes, and other behaviors detrimental to foregut function exponentially increase in the population, adult gastroparetics, whether diabetic, postviral, postsurgical, or idiopathic, are increasingly seen in gastroenterology and GI surgical practices. This has led many surgeons to borrow from the pediatric surgery experience and use a pyloroplasty with a fundoplication for GERD associated with gastroparesis and as a sole procedure for patients with isolated gastroparesis who fail to respond to medical management and who do not qualify for new treatments such as the implantable gastric stimulator.5Salky B. Laparoscopic drainage procedures.Semmin Lapaosc Surg. 1999; 6: 224-228PubMed Google Scholar, 6Farrell T.M. Richardson W.S. Halker R. et al.Nissen fundoplication improves gastric motility in patients with delayed gastric emptying.Surg Endosc. 2001; 15: 271-274Crossref PubMed Scopus (46) Google Scholar Although there is very little literature to support the efficacy of this approach, evidence shows pyloroplasty to be an effective treatment whether gastric emptying is secondary to pyloric dysfunction (spasm, stricture) or gastroparesis (postvagotomy, diabetic gastropathy, postviral, or idiopathic) (Table 1). GES, Gastric Emptying Study. Data from Ziad E, Abouezzi W, Melvin WS, et al. Funtional and symptomatic improvement in patients with diabetic gastroparesis following pyloroplasty. Abstract DDW 1998;abstract #970. Patients with severe gastroparesis are increasingly encountered in gastroenterology and GI surgery practices, and it can be very difficult and frustrating to treat them effectively. The ability to perform an effective and incisionless endoluminal procedure would be a true advance for these unfortunate patients. I believe we will see this come to clinical reality in the not-too-distant future, and it may well prove to be the first step into the future of transenteric endoscopic surgery. DisclosureDr Swanstrom receives research support for NOTES investigations from Olympus and USGI Medical. Dr Swanstrom receives research support for NOTES investigations from Olympus and USGI Medical. Endoscopic pyloroplasty with full-thickness transgastric and transduodenal myotomy with sutured closureGastrointestinal EndoscopyVol. 66Issue 1PreviewPyloroplasty with myotomy and sutured closure is a surgical treatment for gastric outlet obstruction. It has not been previously performed at flexible endoscopy. Full-Text PDF" @default.
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