Clinical Scorecard: Gastric Peroral Endoscopic Pyloromyotomy for Delayed Gastric Conduit Emptying: Treatment Outcomes and Predictors of Response

At a Glance

Key Highlights

• DGCE symptoms after esophagectomy include abdominal pain, nausea, early satiety, heartburn, and regurgitation; approximately 15–50% of patients develop symptoms.
• Initial management generally includes dietary modification and prokinetic therapy, with limited efficacy described in the article.
• For refractory symptoms, options described include botulinum toxin injection, pyloric balloon dilation, surgical pyloroplasty or pyloromyotomy, and GPOEM.
• The prospective study assessed GPOEM safety and efficacy in post-esophagectomy DGCE and examined potential predictors of clinical response.
• Potential patient-selection considerations include symptom profile, 4-hour gastric retention on scintigraphy, prior response to pylorus-directed therapy, and pyloric distensibility measured by EndoFLIP.

Guideline-Based Recommendations

Diagnosis

• Study eligibility required refractory symptoms after esophagectomy, onset more than 3 months postoperatively, and failure of dietary modification and prokinetics.
• At least one objective finding was required: impaired gastric emptying scintigraphy or timed barium swallow, retained solid food in the conduit at gastroscopy, or symptomatic improvement lasting at least 2 months after pyloric botulinum toxin injection.

Management

• Dietary modification and prokinetic therapy are generally used initially for DGCE.
• For refractory symptoms, the article describes botulinum toxin injection, endoscopic pyloric balloon dilation, surgical pyloroplasty or pyloromyotomy, and GPOEM as treatment approaches.
• After GPOEM in the study, patients were hospitalized for at least one night, received high-dose proton pump inhibitors, withheld oral intake for 24 hours, and then advanced from liquid to semi-solid diet before resuming usual diet.

Monitoring & Follow-up

• The study scheduled follow-up endoscopy at 3 and 12 months to assess the pylorus and gastric conduit for dilatation or retained food.
• Solid- and liquid-phase gastric emptying scintigraphy was performed before GPOEM and at 3 and 12 months afterward.
• EndoFLIP pyloric measurements were obtained immediately before GPOEM and 3 months afterward.

Risks

• The article identifies impaired quality of life as a consequence of DGCE symptoms.
• Study exclusions included alternative causes of DGCE, prior pyloric surgery, previous or attempted GPOEM, and uncontrolled coagulopathy.

Patient & Prescribing Data

Adults with refractory DGCE after esophagectomy, with symptoms beginning more than 3 months after surgery and at least one specified objective finding; enrollment occurred from March 2021 through December 2024.

GPOEM was performed under propofol-based sedation or general anesthesia according to center protocols. Patients received prophylactic antibiotics and post-procedure high-dose proton pump inhibitors; the supplied article text does not report treatment outcome results.

Clinical Best Practices

• Assess for objective evidence of DGCE when evaluating refractory symptoms after esophagectomy.
• Consider symptom profile, gastric emptying scintigraphy, prior response to pylorus-directed therapy, and EndoFLIP pyloric distensibility as potential patient-selection factors; the article presents these as considerations, not established predictors.
• For study GES assessments, patients fasted for 8 hours and stopped prokinetic medication for at least 48 hours.
• Before GPOEM, the study protocol used a 3-day liquid diet, a 1-day clear-liquid diet, and a 6-hour fast.

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