Cases and Techniques Library (CTL) E345

Endoscopic pyloromyotomy for postesopha- gectomy gastric outlet obstruction

Fig. 1 A 54-year-old woman presented with vomiting 2 weeks after esophagectomy with gastric pull-up. a Esophagography revealed marked delay in passage of contrast through the pylorus. b Fluid retention was noted on esophago- gastroduodenoscopy (EGD) and the scope could not be passed through the pylorus.

Postesophagectomy gastric outlet ob- vomiting. Esophagogastroduodenoscopy The mucosal entry was then closed using struction occurs in 20% –30% of patients (EGD) revealed significant food stasis in four endoscopic clips (●" Video 1). who undergo esophagectomy and is asso- the pulled-up stomach and again the en- On the following day, fluoroscopy showed ciated with significant morbidity and de- doscope could not be passed through the significant improvement in passage of layed recovery [1]. Recently, endoscopic pylorus. contrast (●" Fig. 3) and the gastroscope pyloromyotomy, also called gastric per- Endoscopic pyloromyotomy was per- (GIF-H260; Olympus) could pass smooth- oral endoscopic myotomy (POEM), has formed with the patient under conscious ly through the pylorus. The patient was been reported, in pigs and in a patient sedation. Saline solution mixed with indi- started on a liquid diet and was dis- with refractory diabetic gastroparesis [2, go carmine was injected on the greater charged the next day. She remains well 3]. We report a case of postesophagec- curvature 5cm proximal to the pylorus. A 10 weeks after the procedure and appro- tomy delayed gastric emptying that was 1.5-cm mucosal incision was made priately tolerates a general diet. successfully treated with endoscopic (●" Fig.2) using a DualKnife (KD-650L; pyloromyotomy. Olympus, Tokyo, Japan). Submucosal Endoscopy_UCTN_Code_TTT_1AO_2AN A 54-year-old woman was referred to the tunneling towards the pylorus was done gastroenterology department because of using Endocut I (E2-D2-I3) (VIO 300D; Competing interests: None vomiting 2 weeks after esophagectomy ERBE, Tübingen, Germany) and Swift This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. with gastric pull-up for esophageal squa- Coag modes (E4-40W). When the scope mous cell carcinoma. Esophagography reached the pylorus, selective circular Hyunsoo Chung1, Bernard Dalle- revealed marked delay in passage of con- and/or oblique myotomy was done. The magne2, Silvana Perretta2, Sang Kil trast through the pylorus and the gastro- outer longitudinal muscle was preserved. Lee1, Sung Kwan Shin1, Jun Chul Park1, scope could not be passed through the Jacques Marescaux2, Yong Chan Lee1 ●" pylorus ( Fig.1). On postoperative day 1 Division of Gastroenterology, Institute 17, endoscopic balloon dilation was per- of Gastroenterology, Severance Hospital, Video 1 formed and it was possible to pass the Yonsei University, Seoul, Korea scope through the pylorus. However, 3 2 Endoscopic pyloromyotomy carried out to treat Department of Surgery, IRCAD, weeks later (postoperative day 39), she postesophagectomy delayed gastric emptying. Strasbourg, France visited our clinic because of recurrent

Chung Hyunsoo et al. Endoscopic pyloromyotomy… Endoscopy 2014; 46: E345–E346 E346 Cases and Techniques Library (CTL)

Fig. 2 Endoscopic pyloromyotomy: a creation of mucosal entry; b submucosal tunneling; c pyloromyotomy; d closure of mucosal entry.

References Bibliography 1 Lanuti M, de Delva PE, Wright CD et al. Post- DOI http://dx.doi.org/ esophagectomy gastric outlet obstruction: 10.1055/s-0034-1377599 role of pyloromyotomy and management Endoscopy 2014; 46: E345–E346 with endoscopic pyloric dilatation. Eur J Car- © Georg Thieme Verlag KG – diothorac Surg 2007; 31: 149 153 Stuttgart · New York 2 Kawai M, Peretta S, Burckhardt O et al. Endo- ISSN 0013-726X scopic pyloromyotomy: a new concept of minimally invasive surgery for pyloric ste- nosis. Endoscopy 2012; 44: 169–173 Corresponding author 3 Khashab MA, Stein E, Clarke JO et al. Gastric Hyunsoo Chung, MD peroral endoscopic myotomy for refractory Gastroenterology, Department of Internal gastroparesis: first human endoscopic py- Medicine loromyotomy (with video). Gastrointest En- Severance Hospital, Yonsei University dosc 2013; 78: 764–768 50 Yonsei-ro Seoul, 120-752

Korea This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. Fax: +82-2-3652125 [email protected]

Fig. 3 Fluoroscopy on the day after endo- scopic pyloromyotomy showed significant improvement in the passage of contrast.

Chung Hyunsoo et al. Endoscopic pyloromyotomy… Endoscopy 2014; 46: E345–E346