Gastric per-oral endoscopic myotomy: Indications, technique, results and comparison with surgical approach

Table 1 Gastroparesis cardinal symptom index

Are you suffering of	None	Very mild	Mild	Moderate	Severe	Very severe
Nausea	0	1	2	3	4	5
Retching	0	1	2	3	4	5
Vomiting	0	1	2	3	4	5
Stomach fullness	0	1	2	3	4	5
Inability to finish a normal sized meal	0	1	2	3	4	5
Feeling excessively full after meals	0	1	2	3	4	5
Loss of appetite	0	1	2	3	4	5
Bloating	0	1	2	3	4	5
Belly visibly larger	0	1	2	3	4	5

Table 2 Surgical and endoscopic options

	PRO	CONS
Surgical options
Pyloromyotomy	(1) High technical success rate; and (2) Improvement in GCSI and GES	(1) Risk of gastric outlet obstruction and leakage; (2) Invasive; and (3) Time consuming
Electrical stimulator	(1) Test response with temporary device; and (2) Predictive features are male sex, diabetic etiology and short duration of disease	High rate of long term complications (infection, erosion, migration, perforation and chronic pain)
Endoscopic options
Botulinum toxin	(1) Easy and tolerable procedure; (2) Repeatable; and (3) Predictive for response to other pyloric techniques	(1) Moot in literature; and (2) Can induce sclerosis and anatomic alteration of pyloric region
Pyloric stent placement	(1) Temporized technique; and (2) Predictive for response to other pyloric targeted techniques	Risk of stent migration and duodenal perforation

GCSI: Gastroparesis cardinal symptoms index; GES: Gastric electrical stimulator.

Table 3 Gastric per-oral endoscopic myotomy

	GPOEM
PRO	High clinical success rate (71%-100%)
	High technical success rate (100%)
	Less perioperative morbidity and operating time than surgery pyloromyotomy
	Minimally invasive
	Short hospitalization time
	Positive predictive factors	Lower starting GCSI
		Fewer symptoms
		Idiopathic and post-surgical GP
CONS	Limited to tertiary care center and very expert physicians
	Risk of pneumoperitoneum and abdominal pain
	Poorer results for diabetic GP and female

GPOEM: Gastric per-oral endoscopic myotomy; GCSI: Gastroparesis cardinal symptoms index.