S5247 Successful Lesser Curve G-POEM With Double Myotomy and Hot Biopsy Muscle Avulsion in the Setting of Medically Refractory Gastroparesis

Introduction: Gastric peroral endoscopic myotomy (G-POEM) has emerged as a promising, minimally invasive therapeutic option for patients with medically refractory gastroparesis, offering symptomatic relief and improvement in gastric emptying in selected patient populations. Recent advancements in intra-procedural techniques aim to enhance procedural safety, precision, and outcomes. Case Description: A 39-year-old woman with medically refractory idiopathic gastroparesis (with 35% retention at 4 hours on emptying study) underwent lesser curvature G-POEM with use of navigational tunneling, double myotomy, and removal of inner muscular bridge. Total procedure time from scope insertion to removal was 20 minutes. There were no procedural complications. The patient was found to have appropriate clinical response with reduction in Gastroparesis Cardinal Symptom Index score at post-procedural follow-up. Discussion: This case highlights the utility of novel intra-procedural techniques in potentially enhancing the efficacy and efficiency of G-POEM. The navigational tunnel technique for G-POEM is an innovative approach first described by Khirfan, et al., designed to identify pyloric landmarks and demarcate them via cautery to create a clear visual path for submucosal dissection. After marking the anatomic landmarks for submucosal tunneling, the endoscopist can utilize a greater or lesser curvature approach for creation of a tunnel. While greater curve approach is most widely used, the lesser curve approach is a modification that offers a more direct and linear path to the pylorus, resulting in a shorter tunnel with potentially faster procedural times. After tunnel creation, a myotomy is performed. In this case, we performed a double myotomy, involving 2 adjacent longitudinal cuts, to enhance durable symptom relief by achieving complete disruption of pyloric function. We then removed the inner bridge of muscle via hot biopsy forceps, which is a novel technique that we propose can result in more effective disruption of pyloric ring and reduced risk of future fibrotic bridging, stricture, or pylorospasm. Continued research, including head-to-head trials, is needed to validate these novel approaches and integrate them into routine clinical practice.