Matthew T. Allemang

How I Do It: Per-Oral Pyloromyotomy (POP)

IntroductionSeveral surgical treatments exist for treatment of gastroparesis, including gastric electrical stimulation, pyloroplasty, and gastrectomy. Division of the pylorus by means of endoscopy, Per-Oral Pyloromyotomy (POP), is a newer, endoluminal therapy that may offer a less invasive, interventional treatment option.MethodsWe describe and present a video of our step by step technique for POP using a lesser curvature approach. The following are technical steps to complete the POP procedure from the lesser curve approach.ConclusionIn our experience, these methods provide promising initial results with low operative risks, although long-term outcomes remain to be determined.

Anatomy of Commonly Performed Bariatric Procedures

The bariatric endoscopist, whether a surgeon or gastroenterologist, should familiarize themselves with the anatomy of the most common bariatric procedures being done today. The following is a summary of the four most common bariatric operations: adjustable gastric banding, Roux-en-Y gastric bypass, vertical sleeve gastrectomy, and biliopancreatic diversion with duodenal switch. Knowledge of expected postoperative anatomy and their endoscopic findings should set a foundation for endoscopic investigations in patients with symptoms and possible postoperative complications.

Completion Gastrectomy with Esophagojejunostomy for Management of Complications of Benign Foregut Surgery

BACKGROUND With the worldwide epidemic of obesity, an increasing number of bariatric operations and antireflux fundoplications are being performed. Despite low morbidity of the primary foregut surgery, completion gastrectomy may be necessary as a definitive procedure for complications of prior foregut surgery; however, the literature evaluating outcomes after completion gastrectomy with esophagojejunostomy (EJ) for benign diseases is limited. We present our experience of completion gastrectomy with Roux-en-Y EJ in the setting of benign disease at a single tertiary center. METHODS AND PROCEDURES All patients who underwent total, proximal, or completion gastrectomy with EJ for complications of benign foregut surgery from January 2006 to December 2015 were retrospectively identified. All cancer operations were excluded. RESULTS There were 23 patients who underwent gastrectomy with EJ (13 laparoscopic EJ [LEJ] and 10 open EJ). The index operations included 12 antireflux, 9 bariatric, and 2 peptic ulcer disease surgeries. Seventy-eight percent of patients had surgical or endoscopic interventions before EJ, with a median of one prior intervention and a median interval from the index operation to EJ of 25 months (interquartile range 9-87). The 30-day perioperative complication rate was 30% with 17% classified being major (Clavien-Dindo ≥ III) and no 30-day perioperative mortality. Comparing laparoscopic and open approaches showed similar operative times, estimated blood loss, and overall complication rate. LEJ was associated with a shorter length of stay (LOS) (P < .001), fewer postoperative ICU days (P = .002), fewer 6-month complication rates (P < .007), and decreased readmission rate (P = .024). CONCLUSION Our series demonstrates that EJ is a reasonable option for reoperative foregut surgery. The laparoscopic approach appears to be associated with decreased LOS and readmissions.