Management of Refractory Gastroparesis

Diagnosis and Classification

The American Gastroenterological Association recommends that refractory gastroparesis requires persistent symptoms, particularly nausea and vomiting, with reliably established gastric emptying delay 1
The American Gastroenterological Association suggests verifying appropriate methodology of gastric emptying studies to ensure accurate diagnosis 2
The American Gastroenterological Association classifies severity based on symptoms and gastric emptying delay: mild, moderate, or severe 3
The American Gastroenterological Association recommends excluding conditions that mimic gastroparesis through careful history, physical examination, and diagnostic tests 2

The American Gastroenterological Association recommends anti-emetic agents as first-line treatment for nausea/vomiting predominant symptoms 2, 3
The American Gastroenterological Association suggests gastric electrical stimulation for patients with intractable nausea/vomiting who have failed standard therapy and are not on opioids 2, 4
The American Gastroenterological Association recommends enteral nutrition via jejunostomy tube when oral intake is inadequate 1, 5
The American Gastroenterological Association recommends neuromodulators, such as tricyclic antidepressants, as first-line treatment for abdominal pain/discomfort predominant symptoms 2, 4
The American Gastroenterological Association advises avoiding opioids as they can worsen gastroparesis 2, 4

The American Gastroenterological Association suggests considering gastric per-oral endoscopic myotomy for select patients with severe gastric emptying delay who have failed standard therapies 2, 4
The American Gastroenterological Association recommends that gastric per-oral endoscopic myotomy should only be performed at tertiary care centers by a team of experts 6, 7
The American Gastroenterological Association notes that pooled analyses show reduction in post-procedure GCSI scores and improved gastric emptying, with 6.8% overall adverse events 7

The American Gastroenterological Association recommends nutritional support for patients with persistent nausea, vomiting, early satiety, and weight loss despite medical therapy 1, 5
The American Gastroenterological Association suggests endoscopic/surgical transjejunal tube or combined gastrojejunostomy tube placed beyond the pylorus 1, 5
The American Gastroenterological Association notes that case series demonstrate weight recovery with acceptable morbidity and mortality 1

The American Gastroenterological Association suggests that laparoscopic pyloroplasty or sleeve gastrectomy may be considered, but their role is unclear due to absence of well-designed trials 1, 5
The American Gastroenterological Association recommends that surgical options should be considered only after all available therapies have been exhausted, preferably at a tertiary care center 1, 5

Pyloroplasty may be considered for patients with severe gastroparesis who have failed standard medical therapies, particularly those with diabetic gastroparesis who show the highest frequency of clinical success (89%) 8
Recent evidence suggests that gastric per oral endoscopic myotomy (G-POEM) or gastric per oral pyloroplasty may be effective for refractory gastroparesis, with pooled analyses showing reduction in post-procedure GCSI scores and improved gastric emptying 9
Pyloroplasty is recommended as a drainage procedure when the stomach is used as an esophageal substitute after esophagectomy 10
G-POEM has shown clinical success rates of 77.5% at 4 years in a large retrospective study, with diabetic gastroparesis showing the best long-term outcomes 8

G-POEM (Gastric Per Oral Endoscopic Myotomy) is an endoscopic technique similar to POEM for achalasia, involving submucosal tunneling and myotomy of the pylorus, and should only be performed at tertiary care centers by a team of experts with extensive experience in treating refractory gastroparesis 9, 8
The overall adverse event rate of G-POEM is 6.8% 9

For refractory cases of gastroparesis, consider G-POEM or surgical pyloroplasty, particularly for diabetic gastroparesis 9, 8
For severe cases with nutritional compromise, consider enteral nutrition via jejunostomy tube 9
Partial or total gastrectomy may be considered as a last resort only after all available therapies have been exhausted 9

G-POEM represents an endoscopic pyloric drainage technique that involves submucosal tunneling and myotomy of the pylorus, similar to peroral endoscopic myotomy (POEM) for achalasia, with a technical approach involving a 1.5- to 2-cm mucosal incision, followed by submucosal tunneling close to the muscularis propria until the pyloric ring is fully exposed with limited extension into the duodenal bulb 11
Complete myotomy of the pylorus is performed and carried out 2 cm proximally into the antrum, with mucosal closure using endoclips or an endoscopic suturing device 11
Most operators favor a greater-curvature approach, though a lesser-curvature approach has been described with similar outcomes, with a "double myotomy" technique involving performing two pyloromyotomy incisions at the index G-POEM 11
The addition of a second incision is not technically challenging and does not markedly prolong procedure time, though additional long-term data are needed 11
Clinical success was achieved in 56% with GCSI score <2 observed in 68% of patients at 12 months 12
G-POEM adverse events include abdominal pain, inadvertent mucosotomy, capnoperitoneum, bleeding, and gastric ulceration 11, 13, 12