Introduction

Gastric peroral endoscopic myotomy (G-POEM) is an emerging endoscopic technique for the treatment of refractory gastroparesis, particularly benefiting patients with pylorospasm. It is considered a safe procedure with a low risk of adverse events when performed by experienced endoscopists. Our aim was to perform a comprehensive analysis of all adverse events associated with G-POEM.

Aims & Methods

We performed a retrospective analysis of prospectively collected data from all patients who underwent G-POEM for gastroparesis at our centers (Prague, Brno) between November 2017 and April 2025. All procedures were performed by a single endoscopist (JM). The primary outcome was procedure-related adverse events rate and severity occurring during the perioperative and early postoperative period. Adverse events were categorized as follows: deviations from the expected peri and postoperative course were defined as "undesirable events." Undesirable events that met the criteria of the Clavien Dindo surgical classification (C-D) were considered "true adverse events".

Results

Out of 70 procedures, no true adverse or undesirable events occurred in 51 procedures (72.9%). Perioperatively, the following undesirable events occurred in 18 patients: : gastric (4; 5.7%) and duodenal mucosal injuries (2; 2.8%), major bleeding during the procedure treated endoscopically (1; 1.4%), serosal perforation (10; 14.3%), capnoperitoneum requiring puncture (3; 4.3%), and subcutaneous emphysema (1; 1.4%). In the early postoperative period, adverse events occurred in 3 patients: one patient complained of significant abdominal pain necessitating analgetics, subsequently, a small leak from the pyloric region to the subhepatic region was described on CT and gastroscopy confirmed ulceration at the tunnel site. The patient responded well to treatment with intravenous proton pump inhibitors. In two other cases, both involving patients with diabetic gastroparesis, decompensation of diabetes occurred during the hospital stay post-procedure. The following “undesirable” events were considered true adverse events according to the C-D classification: serosal perforation (10; C-D I), leak requiring prolonged hospitalization (1; C-D IIIa) and diabetes decompensation (2; C-D II). These complications occurred in 13 procedures (18.6%).
The mean duration of hospitalization after the procedure was 2 days (range 1-7). Three months after the procedure, 1 patient developed mild dumping syndrome, which was successfully treated conservatively.

Conclusion

G-POEM is a safe procedure. The rate of true adverse events according to Clavien-Dindo classification is low and severe AEs occurs rarely.

Clinical Case Summary

Cryptosporidiosis is a gastrointestinal infection caused by the protozoan Cryptosporidium spp. It is typically self-limited in immunocompetent patients. However, in immunocompromised individuals, it can lead to moderate to severe diarrhea and significant morbidity and mortality.¹
We present the case of a 31-year-old woman with a history of Crohn’s disease in remission, who presented with a one-week history of diarrhea (up to 10 bowel movements daily), abdominal pain, and fever (38°C). Laboratory tests revealed an elevated C-reactive protein (CRP), and intestinal ultrasound showed bowel wall thickening, hyperemia and wall disruption, suggestive of an active flare. However, routine stool culture isolated Cryptosporidium, and based on her clinical background, oral paromomycin and azithromycin were initiated, resulting in complete clinical remission.
Cryptosporidiosis is a common parasitic cause of diarrhea, particularly affecting immunocompromised patients, such as those with HIV, cancer or solid organ transplants.²
Although few cases have been described in inflammatory bowel disease (IBD), the immunosuppressive state of these patients may increase the risk of infection. Diagnosing cryptosporidiosis in this population can be challenging, as stool tests detect only about 30% of cases, and the clinical presentation often mimics an IBD flare.³
Treatment is generally supportive and reserved for severe or refractory cases. Nitazoxanide is the drug of choice, and in non-responders, it can be combined with fluoroquinolones or azithromycin. In IBD patients, the decision to initiate specific antiparasitic treatment depends on the degree of immunosuppression and the clinical scenario.⁴
A clear association between IBD and cryptosporidiosis has not been established, but it is crucial to rule out opportunistic gastrointestinal infections in suspected flare-ups before starting specific therapies.
image "Bowel wall thickening, hyperemia, and disruption of the normal layer pattern."

References

(1) Janssen B, Snowden J. Cryptosporidiosis. 2023 Jul 10. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan–. PMID: 28846353.
(2) Liu B, Schnider A, DeArmond M, Banach DB, Haubrich BA. Cryptosporidiosis in individuals with inflammatory bowel disease: a scoping review protocol. BMJ Open. 2024 Oct 15;14(10):e086529. doi: 10.1136/bmjopen-2024-086529. PMID: 39414295; PMCID: PMC11481120.
(3) Ferreira J, Baden R, Magge S, Cheifetz A. Cryptosporidiosis masquerading as a Crohn's flare. Inflamm Bowel Dis. 2011 Oct;17(10):E133-4. doi: 10.1002/ibd.21811. Epub 2011 Jul 7. PMID: 21739536.
(4) Manthey MW, Ross AB, Soergel KH. Cryptosporidiosis and inflammatory bowel disease. Dig Dis Sci 1997;42:1580–6.