Pilot Study: Gastroplasty With Endoscopic Myotomy for Treatment of Obesity

Gastroenterologist holds black endoscope device in hospital setting

One of the proposed mechanisms of weight loss after endoscopic sleeve gastroplasty (ESG) is prolonged satiety due to delayed gastric emptying.

Christopher C. Thompson, MD, director of endoscopy and co-director of the Center for Weight Management and Wellness at Brigham and Women’s Hospital, and colleagues are studying a novel bariatric and metabolic procedure to weaken the antral pump, a major physiologic component of gastric emptying. In Gastroenterology, they report on a pilot study of the procedure, gastroplasty with endoscopic myotomy (GEM), in which a pylorus-sparing antral myotomy is performed before traditional ESG, and found that GEM was technically feasible and safe.

GEM Procedure

GEM consists of three steps:

  • Pylorus-sparing antral myotomy via a submucosal tunneling technique to weaken the antral pump and impede emptying
  • A running suture at the level of the incisura to separate the antrum from the gastric body and minimize tension on the myotomy access site closure
  • Standard ESG in the gastric body to reduce mixing and limit accommodation

A video accompanying the journal article demonstrates the GEM procedure.

Technical Feasibility

All patients underwent GEM successfully:

  • Antral myotomy—A partial-thickness myotomy was performed in three patients and a full-thickness technique in the other three. The mean tunnel length was 9.0 cm, and the mean myotomy length was 7.7 cm. Mucosotomy sites were closed using a mean of one suture and eight stitches
  • ESG—The mean numbers of sutures and stitches placed per sleeve were 8 and 50, respectively. After the procedure, the gastric length was shortened by a mean of 16.0 cm, a mean reduction from the baseline of 67%

The mean length of stay was 1.8 days.


Total weight loss was:

  • 1 month—mean of 12% (P<0.0001)
  • 3 months—mean of 15% (P<0.0001) and >10% in all patients


One patient was readmitted for nausea. At the one- and three-month follow-up visits, no patients endorsed upper gastrointestinal symptoms.

Mechanisms of Action

Before GEM, one patient (17%) had delayed gastric emptying (T1/2 of 204 minutes). Two weeks after GEM, that proportion had increased to 100% (P=0.02), and the mean T1/2 had increased from 90 to 204 minutes (P<0.0001).

The mean score on the postprandial fullness/early satiety subscale of the Gastroparesis Cardinal Symptom Index also increased significantly, from 0.2 to 1.0 (P=0.01).

Looking Ahead

Adding myotomy to ESG may mitigate the effects of suture loss and provide more predictable and durable outcomes. The Brigham team plans further physiologic-based studies of GEM.

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