Predictors of favorable outcome after pyloroplasty for gastroparesis: should response to pyloric dilation or Botox injection be used as a marker of surgical outcome?

Abstract

Introduction Pyloroplasty and gastric peroral endoscopic myotomy (G-POEM) are effective surgeries for gastroparesis. The primary aim of this study was to evaluate outcomes of pyloroplasty and G-POEM in patients with gastroparesis and determine factors associated with favorable outcome. The secondary aim was to assess the utility of clinical response to preoperative pyloric dilation or botulinum toxin injection (Botox) on surgical outcome, a factor conventionally used as a favorable marker. Methods There were 204 patients who underwent pyloroplasty (n = 177) or G-POEM (n = 27) for gastroparesis at our institution from 2014 to 2021. Demographic and clinical parameters were analyzed to assess their impact on surgical outcome. A subgroup of patients who had pyloric dilation or Botox injection were assessed separately. Favorable outcome was defined as patient reported complete resolution of the predominant gastroparesis symptom. Results Favorable outcome was achieved in 78.4% of patients (pyloroplasty: 79.7% and G-POEM: 70.4%, p = 0.274). Among 61 patients where pre- and postoperative gastric emptying studies (GES) were available, mean 4-hour retention significantly improved from 33.5 to 15.0% (p < 0.001) and 77.0% of patients achieved normalization. Favorable outcome was not significantly impacted by etiology of gastroparesis (p = 0.120), GERD (p = 0.518), or primary gastroparesis symptom (p = 0.244). Age ≥ 40 was a significant predictor of favorable surgical outcome on multivariate analysis [OR: 2.476 (1.224–5.008), p = 0.012]. Among the patients who had preoperative dilation (n = 82) or Botox injection (n = 46), response to these interventions was not a predictor of favorable surgical outcome (p = 0.192 and 0.979, respectively). However, preoperative Botox injection, regardless of response to injection, was associated with favorable surgical outcome [OR: 3.205 (CI 1.105–9.299), p = 0.032]. Conclusion Symptomatic improvement after pyloroplasty or G-POEM is independent of etiology of gastroparesis, GERD, and primary symptom. Response to dilation or Botox are not markers of response to surgery. However, patients who receive Botox are 3.2 times more likely to improve postoperatively. Graphical abstract

Role of gastric peroral endoscopic myotomy (GPOEM) in chronic gastroparesis management after pancreas transplantation

“…This aligns with the data in the literature regarding an average of six months to just over two years in both the general and transplant populations 12,38,39 . Some studies have suggested improvement after intrapyloric Botox injections, even temporary, does predict success with more invasive procedures including G‐POEM 40,41 …”

“…12,38,39 Some studies have suggested improvement after intrapyloric Botox injections, even temporary, does predict success with more invasive procedures including G-POEM. 40,41 As we move down the list of possible interventions for gastroparesis, the options become more invasive. Procedures such as placement of a gastric stimulator and pyloroplasty have historically been the next treatment line after medications.…”

Endoscopic Management of Post-Sleeve Gastrectomy Complications

“…Hu et al reported the case of a 61-year-old female post-SG with delayed gastric emptying who underwent per-oral endoscopic pyloromyotomy with a reduction in her gastroparesis symptoms [100]. Additionally, intrapyloric Botulinum toxin injections have been used to treat delayed gastric emptying, including after esophagectomy and pylorus-preserving gastrectomy [101][102][103][104][105][106]. Data regarding the endoscopic use of Botulinum toxin injection of the pylorus in the treatment of stenosis or delayed gastric emptying associated with sleeve gastrectomy are sparse.…”