Lesser curve approach to gastric peroral endoscopic myotomy: a case series

Background and Aims: Gastric peroral endoscopic myotomy (GPOEM) is a promising treatment for refractory gastroparesis. Initially, endoscopists performed GPOEM along the greater curve of the stomach. We, herein, present a novel modification with a lesser curve approach that offers the advantages of shorter tunnel and possibly better myotomy. Methods: Three patients with refractory gastroparesis underwent GPOEM by use of the lesser curve approach. Two of the patients had a prior GPOEM by the traditional greater curve approach. All procedures were performed with the patient under general anesthesia. The specific tools used for incision, dissection, and myotomy are described. The patients were followed up closely, and the gastroparesis cardinal symptom index (GCSI) was calculated before, and 4 weeks after, the procedure. Results: The pyloric ring was exposed very well with the lesser curve approach. The mean procedure time was 48 ± 12 minutes. No immediate or late adverse events were observed. All patients had significant improvement in the GCSI 4 weeks after GPOEM, with resolution of gastroparesis symptoms. The mean follow-up time was 6 months. Conclusion: The lesser curve approach to GPOEM provides an excellent exposure to the pyloric ring and can be used as a primary or a salvage technique for the treatment of refractory gastroparesis.