Gastroparesis, treated with pyloric endoscopic myoablation, with a novel superpulse thulium fiber laser, and mucosal defect closure with endoscopic hand suture. These are our disclosures. The short-term success rate of the G-POEM for gastroparesis is around 50-80%. Standard myotomy often creates only a short distance between the muscular fibers, which increase the risk of them reconnecting during healing. Debulking a larger segment of the pylorus could therefore potentially prevent the fibers from reconnecting. We present the case of a 72-year-old male with symptomatic gastroparesis as complication from failed reflux surgery. He has been dilated twice in the pylorus, up to 25 mm, with a short-term effect. In this case, we demonstrate how to use a superpulse thulium fiber laser for ablation of soft tissues and closing of the mucosal defect with endoscopic hand suture. On examination of the pylorus initially, it was difficult to pass the gastroscope. In this case, we aim to perform G-POEM and myoablation of the pylorus using a novel superpulse thulium fiber laser with a 365 micron probe. Closing the mucosal defect with a conventional clip after G-POEM can be technically difficult due to the mucosal detachment from the muscular wall. Therefore, we decide to close the mucosal defect in this case with endoscopic hand suture. The mucosal was punctured with laser before injection with a catheter with a solution of saline-inducalmine for a supramucosal lift. And then we entered the tunnel with a scope and did the dissection towards the pylorus. All the visible blood vessels were prophylactically coagulated with the laser. After reaching the pylorus, we perform myoablation. In this case, we use different energy setting where we can disintegrate the muscle fibers. When using the laser underwater, we don't see any smoke. All the organic material are dispersed in microbubbles. With myoablation, we just ablate a larger chunk of the pyloric muscle fibers. In this case, over a quarter of this pyloric circle. The mucosal tunnel opening was then closed with endoscopic hand suture with a 3-O barbed absorbable sutures. No interoperative complication occurred and the patient could resume food the same day. At 6 weeks control, the patient didn't have any symptoms. On endoscopy, we can see an open pylorus. Some part of the thread, which has not been absorbed, could easily be removed with the forceps. In conclusion, Thulium fiber laser can be used for all the steps of G-POEM Thulium fiber laser can be used for all the steps of G-POEM including mucosal incision, semicosal dissection, coagulation and muscular fiber cutting and ablation. The Thulium fiber laser characteristics allow for precise and efficient tissue ablation safely. Due to the detachment between the mucosal and muscular wall, endoscopic hand suture can be useful to close mucosal defect after G-POEM.

gastroparesis

thulium fiber laser

pyloric endoscopic myoablation

mucosal defect closure

G-POEM