Breaking the Gastroparesis Bottleneck: Gastric Peroral Endoscopic Myotomy versus Pyloroplasty—a Narrative Review

Abstract

Gastroparesis is a chronic gastric motility disorder characterized by delayed gastric emptying and debilitating symptoms. In refractory cases, interventions targeting the pylorus (gastric peroral endoscopic myotomy [G-POEM] and surgical pyloroplasty) have emerged as effective therapeutic options. This narrative review compares the efficacy, safety, durability, and cost-effectiveness of G-POEM and pyloroplasty in adult patients with medically refractory gastroparesis.

Both G-POEM and pyloroplasty demonstrate comparable clinical efficacy, with 70 to 80% of patients achieving symptom improvement and enhanced gastric emptying, irrespective of underlying etiology (idiopathic, diabetic, or post-surgical). G-POEM offers advantages in procedural time, recovery, complication rates, and cost, while surgical pyloroplasty shows marginally superior improvements in objective gastric emptying in select cohorts. Long-term durability is comparable, though symptom recurrence may affect up to 30 to 50% by 5 years. G-POEM is repeatable and preserves future surgical options, whereas surgical pyloroplasty remains a definitive intervention.

Both G-POEM and pyloroplasty are effective, safe, and durable interventions for refractory gastroparesis. G-POEM offers a minimally invasive, cost-effective alternative with similar efficacy, making it a preferred first-line intervention in appropriately selected patients. Individualized therapy based on anatomy, expertise, and patient preference is key to optimizing outcomes.

 

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Keywords

gastroparesis - G-POEM - pyloroplasty - myotomy - gastric motility - GCSI

Background and Rationale for Pyloric Therapies

Gastroparesis is a chronic motility disorder characterized by delayed gastric emptying in the absence of mechanical obstruction. Patients suffer from nausea, vomiting, early satiety, bloating, and abdominal pain, often quantified by instruments like the Gastroparesis Cardinal Symptom Index (GCSI). In refractory cases (symptoms despite dietary modifications and prokinetic/antiemetic therapy), interventions targeting the pylorus have emerged as effective options.[1] [2] Pylorospasm and pyloric dysfunction are thought to contribute to gastroparesis symptoms, prompting therapies that disrupt or widen the pyloric sphincter to facilitate gastric emptying.[3] Two major pylorus-directed interventions have gained prominence in the past decade:

• Gastric peroral endoscopic myotomy (G-POEM): also called peroral endoscopic pyloromyotomy, this is a minimally invasive endoscopic procedure adapted from POEM for achalasia. An endoscopist performs a submucosal tunneling and full-thickness myotomy of the pyloric sphincter entirely via the stomach lumen, avoiding external incisions.[3] [Fig. 1] shows myotomy of the muscle during a G-POEM. First reported around 2013 to 2015, G-POEM has quickly been adopted at specialized centers for medically refractory gastroparesis.

• Surgical pyloroplasty: a traditional surgical approach (open, laparoscopic, or robotic) in which the pylorus is surgically cut and reconstructed to widen the gastric outlet. The most common technique is a Heineke–Mikulicz pyloroplasty (longitudinal incision closed transversely), often performed laparoscopically.[3] Pyloroplasty has a longer history, including use in gastroparesis and as an adjunct to vagotomy or esophagectomy. Modern series have applied laparoscopic pyloroplasty as primary therapy for refractory gastroparesis with reported success.[1] [2]

Fig. 1 Myotomy during G-POEM. G-POEM, gastric peroral endoscopic myotomy.

Both approaches aim to improve gastric emptying and relieve symptoms by permanently reducing pyloric resistance. This review compares G-POEM and surgical pyloroplasty in adult gastroparesis, including efficacy across etiologies, symptom improvement (GCSI scores), complication rates, outcomes over time, and cost-effectiveness ([Fig. 1]).

 

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Efficacy Across Gastroparesis Etiologies

Gastroparesis has diverse etiologies—most commonly idiopathic, diabetic, and post-surgical (e.g., after fundoplication or vagal nerve injury). A key question is whether underlying etiology influences outcomes of pyloric interventions. Recent evidence suggests that both G-POEM and pyloroplasty can be effective across all major etiologic subgroups, with somewhat comparable response rates.

• A 2024 meta-analysis of 15 G-POEM studies stratified by etiology (total n = 982 patients) found no significant difference in clinical success between diabetic, post-surgical, or idiopathic gastroparesis.[4] Pooled symptom improvement (“clinical success”) rates after G-POEM were 65% for diabetic gastroparesis, 70% for post-surgical, and 60% for idiopathic, with overlapping confidence intervals.[4] G-POEM led to significant GCSI score improvements in all groups (mean GCSI reduction 1.3–1.7 points) irrespective of etiology. These results indicate G-POEM's efficacy is not limited to a particular subtype of gastroparesis—even the traditionally challenging diabetic cases showed 2/3 response rates in this large analysis.[4]

• Earlier analyses had hinted idiopathic patients might respond best to G-POEM. For instance, Mohan et al noted on meta-regression that idiopathic gastroparesis (as well as prior therapies like botulinum toxin or gastric electrical stimulation) predicted higher odds of G-POEM success.[5] However, overall, their meta-analysis did not find a significant outcome difference by etiology, aligning with the newer data.

• For surgical pyloroplasty, most series likewise report benefit across etiologies. In the previously mentioned largest surgical case series[1] [2] (Shada et al: 177 patients), 63% were idiopathic, 20% post-surgical, 17% diabetic, and no subgroup was excluded from the overall 86% rate of gastric emptying improvement and symptom relief post-pyloroplasty. A propensity-matched study by Landreneau et al specifically matched patients by etiology (63% idiopathic, 20% post-surgical, 17% diabetic in each arm) and found equivalent symptomatic outcomes between laparoscopic pyloroplasty and G-POEM, regardless of cause.[6] Similarly, a multi-center comparative study noted that diabetic and idiopathic gastroparesis responded to both procedures; interestingly, in that series post-surgical patients were more likely to be referred for G-POEM than surgery (26% vs. 14%) but outcomes were similar.[7]

In summary, neither procedure is categorically limited to a specific gastroparesis etiology. Idiopathic and post-surgical patients often show excellent responses to pyloric therapies.[4] [5] Diabetic gastroparesis historically was thought to respond less robustly, perhaps due to diffuse neuropathy, but modern studies report meaningful improvement in a majority of diabetic patients as well.

Thus, patient selection for G-POEM versus pyloroplasty can be guided more by clinical factors and preference rather than etiology alone. Both interventions target a final common pathway (pyloric dysfunction) that appears to transcend the upstream cause of gastroparesis.

 

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Symptom Relief and GCSI Outcomes

Symptom improvement is the primary goal of any gastroparesis intervention. Standardized tools like the GCSI allow quantification of symptom severity (score range 0–5) and have been widely used to define clinical success (often as a reduction of ≥1 point in GCSI). The evidence indicates that G-POEM and pyloroplasty produce comparable symptomatic relief in most studies, with the majority of patients experiencing significant improvement by 3 to 6 months post-procedure:

• Comparative efficacy: in head-to-head comparisons, G-POEM has performed as well as surgery in alleviating symptoms. A meta-analysis by Mohan et al pooled 11 G-POEM studies (332 patients) and 7 pyloroplasty studies (375 patients) and found no statistical difference in symptom relief between the two modalities.[5] The pooled clinical success rate based on GCSI was 76% for G-POEM versus 77% for pyloroplasty (p = 0.81). Likewise, the newer 2023 systematic review by Aziz et al, which included only direct comparative studies, found post-procedure GCSI scores were equivalent between G-POEM and surgical pyloroplasty.[3] In that analysis, the mean GCSI after treatment was 2.4 in both groups (on a 0–5 scale), with a mean GCSI reduction of roughly 1.0 to 1.3 from baseline in both—a clinically significant improvement.

• Magnitude of symptom improvement: patients undergoing either procedure typically report substantial relief. For example, in a multicenter cohort, both groups had high response rates—92.3% of G-POEM patients and 82.5% of pyloroplasty patients achieved clinical success (defined by symptom improvement, p = 0.16).[8] G-POEM patients in that study had a greater drop in GCSI (on average 1.3 points more reduction than surgery, p < 0.00001),[8] suggesting a trend toward more pronounced symptom relief, although both groups improved significantly. Landreneau's matched study likewise reported that GCSI scores improved significantly and similarly in both groups (mean final GCSI −2.4 in each, from baselines −4.0).[1] These findings are echoed by other series and patient-reported outcomes. Toro et al[1] documented 82% of patients feeling symptom improvement 1 month after laparoscopic pyloroplasty,[1] and long-term surveys after G-POEM show the majority of patients remain glad they underwent the procedure despite some symptom recurrence (in one 6-year follow-up, 77% of patients were satisfied with having had G-POEM).[9]

• Symptom indices and quality of life: beyond GCSI, studies have measured specific symptom domains (e.g., nausea, vomiting frequency) and generic quality of life. Improvements in nausea/vomiting and bloating are especially pronounced. Shada et al noted significant decreases in nausea, vomiting, bloating, abdominal pain, and early satiety scores by 3 months after pyloroplasty.[2] G-POEM studies likewise report improvement across all cardinal symptoms; for instance, one prospective series showed reductions in nausea/vomiting scores by 50% at 6 and 12 months post-G-POEM.[10] Patients often experience the most dramatic relief in vomiting frequency and the ability to tolerate solid food, which correlates with improved gastric emptying.

• Responder rates: defining a “responder” as GCSI reduction ≥1 or ≥30–50% has yielded responder rates in the 60 to 80% range for both procedures. In the randomized-controlled setting (albeit vs. sham or other therapy), G-POEM has proven its benefit: a sham-controlled trial recently demonstrated significantly greater GCSI improvement with G-POEM than sham, validating that the symptom relief is attributable to the intervention. While no randomized controlled trial compares G-POEM to pyloroplasty directly, the consistent 70 to 80% response rates in uncontrolled series for each suggest they are roughly on par.[1] [5]

Taken together, the evidence indicates that G-POEM and surgical pyloroplasty offer comparable symptomatic benefit for refractory gastroparesis.

[Table 1] summarizes symptomatic outcomes from key studies. G-POEM may confer a slightly faster or larger GCSI drop in some cohorts,[8] but meta-analytic data show no significant difference in final symptom scores between the modalities.[3] Importantly, a substantial minority (20–30%) of patients do not respond adequately to either approach, underscoring that patient selection and managing expectations remain crucial.

Table 1 Symptom relief and gastric emptying outcomes in G-POEM versus surgical pyloroplasty

Study, year	Patients (G-POEM vs. surgery)	Symptom/clinical success	Gastric emptying (GES) improvement
Landreneau et al, 2019[6] (propensity-matched cohort)	30 vs. 30	Significant GCSI improvement in both (post-op GCSI-2.4 in both; no difference)	Normalized GES in 86% vs. 83% (4-hour emptying normalized; no difference, p = 0.91)
Pioppo et al, 2021[8] (multicenter cohort)	39 vs. 63	92.3% vs. 82.5% achieved clinical success (≥1 GCSI point improvement; p = 0.16). G-POEM had greater mean GCSI drop (by 1.3 points more than surgery, p < 0.00001)	Both groups improved gastric emptying; G-POEM had 25% greater 4-hour retention reduction vs. surgery (p < 0.00001). (Baseline 4-hour retention reduced more with G-POEM).
Mohan et al, 2020[5] (meta-analysis, 11 G-POEM & 7 surg studies)	332 vs. 375	75.8% vs. 77.3% pooled GCSI clinical success (no statistical difference, p = 0.81). Symptom scores improved significantly from baseline in both groups.	85.1% vs. 84.0% pooled rate of GES normalization/improved emptying (no difference, p = 0.91). Both interventions significantly improved 4-hour scintigraphy results.
Eriksson et al. 2025[7] (single-center retrospective)	81 vs. 233	70.0% vs. 76.4% had resolution of predominant symptom at mean 14-month follow-up (no significant difference, p = 0.30). Median GCSI improved to 2.4 in both groups (from ∼3.1)	GES 4-hour retention improved in both: median 4-hour retention dropped from 29% to 4% with surgery vs. 23% to 13% with G-POEM. ≥50% reduction in 4-hour retention in 50% vs. 70% of patients (trend favoring surgery, p = 0.086). No significant difference in final GES between groups (p = 0.07).

Abbreviations: GCSI, Gastroparesis Cardinal Symptom Index; GES, gastric emptying scintigraphy (typically 4-hour retention).

Note: Clinical success generally denotes a meaningful symptom improvement per study criteria (often ≥1 point GCSI decrease). As shown, both interventions yield similar symptom relief rates across studies, with no statistically significant differences in pooled analyses. Gastric emptying also improves with both, although one study noted a trend toward greater objective emptying improvement after surgical pyloroplasty. Overall, outcomes are comparable, highlighting that less invasive G-POEM can achieve symptomatic and emptying results on par with surgery in refractory gastroparesis.

 

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Objective Gastric Emptying Outcomes

While symptom improvement is paramount, objective gastric emptying (typically measured by scintigraphy) provides supportive evidence of physiological benefit. Interestingly, symptom relief and emptying do not always correlate perfectly in gastroparesis; however, successful pyloric therapies often show improvements in both domains. Key findings regarding gastric emptying are:

• G-POEM: most studies show a significant reduction in gastric retention on nuclear scintigraphy after G-POEM. In one systematic review, 85% of G-POEM patients had improved or normalized gastric emptying post-procedure.[5] For example, a Chinese series reported >80% of patients achieving normal 4-hour emptying after G-POEM.[5] In the largest long-term G-POEM follow-up, gastric retention at 4 hours decreased from a mean −22% pre-procedure to −12% post-procedure, among those with sustained clinical response.[11] Notably, even the sham-controlled trial of G-POEM (Gonzalez et al) documented significant emptying acceleration with G-POEM versus no change with sham, confirming a true physiological effect. That said, a subset of G-POEM patients can improve symptomatically without full normalization of emptying, and vice versa.

• Pyloroplasty: surgical pyloroplasty is highly effective at accelerating gastric emptying. In the Emory study by Toro et al, median gastric emptying t _½ fell from 180 minutes pre-op to 60 minutes post-op (p < 0.001), with 96% of tested patients showing improved emptying and 60% achieving complete normalization.[1] Similarly, Shada et al saw gastric emptying normalized in 77% of patients after laparoscopic pyloroplasty (and improved in 86%).[2] These objective outcomes are impressive and illustrate that pyloroplasty reliably relieves the bottleneck at the pylorus. Improved emptying has also been observed in diabetic gastroparesis patients after pyloroplasty, although extremely poor baseline motility may not fully normalize.

• Comparative results: head-to-head comparisons generally show no significant difference in gastric emptying outcomes between G-POEM and pyloroplasty, mirroring the symptom results. Landreneau et al reported 86% of G-POEM versus 83% of pyloroplasty patients attained normal gastric emptying post-intervention (p = 0.91).[3] The meta-analysis by Mohan et al found virtually identical pooled 4-hour emptying success rates (∼85% each).[5] However, one institutional study (Eriksson et al) did find a trend toward greater emptying improvement with surgery: in their cohort, 70% of surgical patients had ≥50% reduction in 4-hour retention versus 50% of G-POEM patients (p = 0.086).[7] Median post-op retention was lower after pyloroplasty (4% vs. 13%, p = 0.07) despite similar symptom outcomes. This suggests that while both procedures improve emptying, pyloroplasty might achieve a more complete physiological correction in some cases (perhaps due to a larger or more durable pyloric opening). The clinical significance of this difference is unclear since symptoms were equivalent—it underscores that symptom relief can plateau once a threshold of improved emptying is reached.

• Retention versus symptom disconnect: it is worth noting that some patients with normalized emptying still have symptoms (implying other pathophysiology like visceral hypersensitivity), whereas others with persistent delayed emptying may feel much better. Both G-POEM and pyloroplasty have instances of this mismatch. These differences may be attributed to different etiologies for gastroparesis. It is widely known that gastroparesis is a multifactorial condition. Particularly diabetic gastroparesis tends to respond less favorably to pyloric interventions as compared with other etiologies. Toro et al noted five patients (10%) who had normalized emptying after pyloroplasty but nonetheless required further interventions for symptom control (e.g., gastrectomy or jejunostomy).[1] Thus, improved emptying is neither absolutely necessary nor sufficient for symptomatic benefit, but in general it correlates positively.

In summary, both G-POEM and surgical pyloroplasty significantly improve gastric emptying in the majority of gastroparesis patients. Many patients attain normal gastric emptying after either intervention. Surgical pyloroplasty has a long track record of normalizing emptying in 60 to 80% of cases and G-POEM appears to achieve a similar impact in modern series. Slight differences in objective metrics have been observed in some studies (with surgery perhaps yielding a bit lower post-op retention on average), but these have not translated into significant differences in patient outcomes in controlled comparisons. Thus, from a physiologic standpoint, G-POEM replicates the effect of pyloroplasty by relieving the pyloric outflow obstruction, explaining the parallel symptom improvements.

 

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Procedure Characteristics and Perioperative Outcomes

One area where G-POEM and surgical pyloroplasty diverge is in procedural invasiveness and immediate postoperative recovery. G-POEM is markedly less invasive, which confers advantages in procedure time, blood loss, and hospital stay. Key comparative points include:

• Procedure time: endoscopic pyloromyotomy is generally faster to perform than a surgical pyloroplasty. In comparative studies, G-POEM tends to have a shorter procedure duration by approximately 20 to 60 minutes. Pioppo et al reported mean procedure times of 58 minutes for G-POEM versus 78 minutes for laparoscopic pyloromyotomy (a 20-minute reduction, p < 0.00001).[8] Landreneau et al's single-center study saw an even larger difference: 34 minutes for G-POEM versus 99 minutes for lap pyloroplasty (possibly some surgical cases were complex reoperations, p < 0.001).[6] A 2023 meta-analysis confirmed G-POEM is significantly shorter in duration, with a pooled mean difference of 59.5 minutes compared with surgery (p < 0.001).[3] The endoscopic approach avoids the time needed for abdominal entry, closure, and pyloric suturing. Faster operative times can reduce anesthesia exposure and potentially lower costs.

• Hospital length of stay (LOS): because G-POEM causes minimal external trauma, patients recover more quickly and often require only an overnight observation (some centers even discharge same-day). Multiple studies demonstrate a dramatically shorter post-procedure hospitalization with G-POEM. In Pioppo et al's series, hospital stay averaged 1.3 days for G-POEM versus 4.1 days for surgery (nearly 3 days shorter, p < 0.00001).[8] Landreneau et al similarly found 1.4 versus 4.6 days (p = 0.003).[6] The meta-analysis by Aziz et al found a pooled reduction of 3.1 days in LOS with G-POEM (p < 0.001).[3] Many G-POEM patients tolerate liquids within 24 hours and resume diet quickly, whereas surgical patients may need slower advancement and pain management, explaining the discrepancy. Shorter LOS not only improves patient comfort but is a major driver of cost savings for G-POEM (see the “Cost-Effectiveness Considerations” section below).

• Perioperative recovery: G-POEM is performed trans-orally under endoscopic guidance, so it avoids abdominal incisions and external scars. Blood loss is negligible—often just a few milliliters from mucosal entry. In Pioppo et al's comparison, the mean blood loss in G-POEM was 3.6 versus 866 mL during surgical pyloromyotomy. (The surgical group's higher blood loss was partly due to one open conversion in that series and the inherent bleeding risk of dividing muscle and suturing.) Avoiding an abdominal operation also means less post-op pain for G-POEM patients and no risk of wound complications or hernias. Patients undergoing pyloroplasty, in contrast, have small incisions (laparoscopic ports or a mini-laparotomy) and may experience more pain and ileus in the immediate postoperative period.

These differences are illustrated in [Table 2]. The minimally invasive nature of G-POEM clearly offers perioperative advantages over surgical pyloroplasty, which translate to shorter and easier recovery for patients.

Table 2 Procedural and perioperative outcomes

Study (year)	Operative time (G-POEM vs. surgery)	Hospital stay (G-POEM vs. surgery)	Adverse event rate (G-POEM vs. surgery)
Landreneau et al (2018)[6]	33.9 vs, 99.0 minutes (laparoscopic pyloroplasty)	1.4 vs. 4.6 days	3.3% vs. 16.7% had complications (NS trend, p = 0.086). No leaks in either group; surgery had a few infections/pneumonia.
Pioppo et al (2021)[8]	58 vs. 78 minutes (mean; G-POEM 20-minute shorter, p < 0.00001)	1.3 vs. 4.1 days (mean LOS 2.8 days shorter with G-POEM, p < 0.00001)	13% vs. 33% had procedure-related adverse events (p < 0.05). G-POEM complications mostly mild (e.g., abdominal distension); surgery had higher risk (bleeding, infections).

Abbreviations: G-POEM, gastric peroral endoscopic myotomy; LOS, length of stay; NS, not statistically significant.

Note: G-POEM is associated with significantly shorter procedure duration, less blood loss, and shorter hospital stay than surgical pyloroplasty. Complication rates were lower with G-POEM in these studies (significantly so in the larger Pioppo cohort). These findings highlight the less invasive nature of G-POEM leading to faster recovery.

 

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Safety and Complication Rates

Both G-POEM and pyloroplasty are considered relatively safe interventions, especially when performed in high-volume centers. There is no mortality reported in the major series for either procedure. However, the adverse event profiles differ due to the nature of endoscopic versus surgical approaches:

• G-POEM complications: G-POEM is generally well-tolerated. A pooled analysis of >300 G-POEM patients found an overall adverse event rate of 11%.[10] Most complications are minor and can be managed conservatively or endoscopically. The most common issues include:

  • – Capnoperitoneum (peritoneal CO₂ insufflation): this is frequently encountered due to the transmural myotomy. It is usually asymptomatic or causes transient abdominal distension and shoulder pain; decompression with a needle tap is occasionally required. It is reported in up to 10 to 15% of cases, but rarely of clinical consequence.[8]

  • – Mucosal perforation or leak: if the mucosal entry or closure fails, a full-thickness perforation could occur. Thanks to the dual-layer closure (inner circular muscle remains intact except at the myotomy site) and use of endoscopic clips, clinically significant leaks are uncommon (<2%). In experienced hands, mucosal breaches are immediately closed. Notably, studies like Landreneau et al and Pioppo et al had zero full-thickness leaks in G-POEM arms.[8]

  • – Bleeding: bleeding can happen from the tunneling or myotomy site, but is usually controlled endoscopically during the procedure. Post-procedure gastrointestinal bleeding is rare. No significant hemorrhages were reported in the comparative studies.[8]

  • – Others: post-procedural nausea or pain occurs in some patients but usually resolves within days. Infection risk is low (prophylactic antibiotics are often given). There is no abdominal wound, so no risk of wound infection or hernia. Some patients may develop acid reflux or bile reflux gastritis after G-POEM due to an open pylorus, but this appears infrequent and less severe than gastroesophageal reflux disease after esophageal POEM (data are limited; most G-POEM patients do not report new reflux symptoms due to overlapping nature of symptoms).

• Surgical pyloroplasty complications: pyloroplasty involves abdominal surgery and thus carries typical surgical risks, albeit at low rates in expert centers. Reported complication rates for laparoscopic pyloroplasty range from 5 to 20% of patients.[6] Observed complications include:

  • – Infections: surgical site infection (port-site or intra-abdominal abscess) occurs in a small fraction (5%). Landreneau et al had a 6.7% incidence of wound infection (none in the G-POEM group). Pneumonia or urinary infections can also occur postoperatively in a few patients, especially those hospitalized longer.

  • – Pyloroplasty leak: an anastomotic leak at the pyloroplasty site is a serious but rare complication. In a large series of 177 pyloroplasties, 2 patients (1.1%) had confirmed leaks treated with surgical revision.[1] [6] Many high-volume surgeons report 0% leaks in their series. Meticulous two-layer suturing and avoidance of tension are key to preventing leaks.

  • – Bleeding: intraoperative bleeding can occur, but significant hemorrhage is uncommon (<2%) and usually controlled during surgery. The need for transfusion is rare; however, as noted, average blood loss can be higher than in G-POEM (hundreds of mL vs. virtually none).

  • – Postoperative ileus: some surgical patients experience a transient ileus (delayed return of bowel function), prolonging hospitalization. This tends to be mild for laparoscopic surgery.

  • – Others: there is minimal risk of long-term complications like incision hernia (especially with pure laparoscopy). Pyloroplasty can, in theory, lead to bile reflux into the stomach since the pylorus is permanently open; patients are sometimes co-treated with acid suppression if needed. In combined surgeries (fundoplication + pyloroplasty), care is taken to prevent bile reflux esophagitis.

• Comparative safety: direct comparisons indicate G-POEM has a lower or equal complication rate relative to surgery. In the multicenter study, adverse events occurred in 13% of G-POEM patients versus 33% of surgical patients (p < 0.05).[8] Landreneau et al's matched study found 3.3% versus 16.7% (p = 0.086, a strong trend).[6] The types of complications also differ in severity: G-POEM tends to be minor (no G-POEM patient in these series required reoperation), whereas a few surgical patients did require interventions (e.g., one needed intensive care unit care for pneumonia in Landreneau et al's cohort). Overall, no significant long-term adverse effects of G-POEM or pyloroplasty have surfaced in follow-up studies. G-POEM does not seem to negatively affect subsequent surgical options—one can still perform a pyloroplasty or even gastrectomy later if needed (the scar at the pylorus from G-POEM is minimal). Conversely, doing a pyloroplasty first does not preclude later endoscopic therapy, though usually if surgery fails, the next step might be a gastric stimulator or subtotal gastrectomy.

In summary, both procedures are safe, with low morbidity, but G-POEM enjoys a slightly better safety profile (fewer and milder complications) in comparative studies.[8] The avoidance of external surgery with G-POEM eliminates many risk factors associated with surgical complications. Importantly, there have been no procedure-related deaths reported for either G-POEM or pyloroplasty in the gastroparesis literature of the past decade—a testament to the safety of both in experienced hands. Careful patient monitoring and expertise in managing complications (endoscopic or surgical) further mitigate serious adverse outcomes.

 

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Short-Term versus Long-Term Outcomes

When comparing interventions, one must consider not only the initial success but also the durability of symptom relief. Gastroparesis is a chronic condition and symptoms can recur over time, either due to disease progression or pyloric muscle regeneration/fibrosis. Key points on short- and long-term outcomes:

• Short-term outcomes: both G-POEM and pyloroplasty yield their maximal benefit within weeks to a few months post-procedure. By 3 months, responders declare themselves with improved GCSI scores, and gastric emptying is typically re-measured at 4 to 6 weeks or 3 months showing improvement. The short-term (3–6 month) success rates are around 70 to 80% as noted earlier.[5] [8] At 6 months, G-POEM has been shown to significantly improve quality-of-life scores in responders. Likewise, surgical series note high patient satisfaction at early follow-up: e.g., 82% symptom improvement at 1 month after pyloroplasty.[11] Early symptomatic relapse is relatively uncommon; most patients who will benefit do experience substantial relief initially.

• 1-year outcomes: at approximately 1 year, studies suggest a modest attrition in the proportion of patients with ongoing relief, but the majority remain improved. In the long-term follow-up by Abdelfatah et al, 69.1% of G-POEM patients had a sustained clinical response at 12 months.[11] Interestingly, among those who responded at 3 months, 85.2% were still responders at 1 year, indicating that early responders usually maintain their benefit through at least a year. Surgical pyloroplasty series with 1-year data are sparse, but it is generally thought that if a pyloroplasty is going to fail, it often does so earlier (e.g., from a leak or stricturing—which are rare). Otherwise, one might expect stability of the result at 1 year, as the pylorus remains open. Some surgical case series document durable symptom improvement at median approximately 14 months follow-up, as in Eriksson et al's study, where approximately 75% were still doing well.

• Beyond 1 year (long-term durability): longer term data (≥2–5 years) are now emerging, especially for G-POEM, which is newer. Results indicate that a significant fraction of patients maintain symptom improvement for several years, but some do experience recurrence.

  • – G-POEM: multiple studies indicate approximately 50 to 70% of patients have durable benefit at 2 to 3 years. A meta-analysis of G-POEM outcomes beyond 12 months found approximately 70% clinical success up to 3 years.[12] [13] Another meta-analysis showed a pooled clinical success of 76% at 36 months.[12] One multicenter series reported symptom relapse in 20% of initial responders by 2 years, often requiring a repeat G-POEM or alternative therapy. The longest follow-up report (Wills et al) contacted patients a median of >5 years after G-POEM: they found only 33.3% maintained a ≥1 point GCSI improvement in those interviewed, with the overall mean GCSI sliding back from 3.7 (pre) to 2.8 post-procedure (still improved, p < 0.01).[14] Notably, even among some whose symptoms recurred, many were glad to have undergone G-POEM and some sought repeat interventions. A few patients in that series ultimately died of unrelated causes (gastroparesis can be comorbid with severe diabetes, etc.), underscoring the chronic nature of the condition.[14] In summary, G-POEM's effect can attenuate over years for a subset of patients, possibly due to ongoing neuromuscular degeneration or pyloric scarring. In a single-center series on post-surgical gastroparesis, the clinical response remained durable even after 5 years of procedure.[15]

  • – Surgical pyloroplasty: long-term data specifically for gastroparesis are less abundant, but indirect evidence and older studies suggest reasonably durable outcomes. For instance, pyloroplasty has been used in combination with gastric electrical stimulation; one analysis found patients who had both stimulator and pyloroplasty tended to have better 5-year symptom control (82% vs. 62% success at 5 years, p = 0.066) than those with stimulator alone.[16] This implies pyloroplasty's benefit persists and contributes years later. Clinically, if a pyloroplasty is effective initially, the anatomic change is permanent, so symptoms would recur only if gastroparesis pathology progresses or if the pyloric scar contracts (the latter is uncommon—pyloroplasty tends to stay patent). Anecdotally, some patients do report return of symptoms years later and might then undergo additional interventions (e.g., gastric stimulator or Botox injections), but systematic 5+ year follow-ups are lacking. In Toro et al's series, approximately 10% required additional surgery down the line despite initial success.[1] Shada et al noted 11% of patients eventually went on to require feeding tubes or a gastrectomy after pyloroplasty during long-term management.[2] Therefore, as with G-POEM, not all gains are permanent—gastroparesis can remain a management challenge in a subset.

• Repeat or additional interventions: if symptoms recur or persist, can the treatments be repeated? For G-POEM, there have been reports of repeated G-POEM (performing a second myotomy) with some success, especially if the first myotomy was thought to be incomplete or if scar formation is suspected. The data on repeat G-POEM are limited but suggest it is feasible. For surgical pyloroplasty, repeating the surgery is generally not done—if it fails, the next step might be a near-total gastrectomy or jejunal feeding tube for nutritional support. Importantly, because G-POEM does not preclude future surgery, one strategy is to attempt G-POEM first (given its lower invasiveness) and resort to surgical pyloroplasty or gastrectomy only if needed later. This staged approach can spare many patients an upfront surgery.

In summary, short-term outcomes (up to 1 year) for both G-POEM and pyloroplasty are excellent, with around 70 to 80% of patients enjoying major symptom relief. Long-term outcomes (several years) remain favorable for a significant proportion, but there is attrition in response: roughly 30 to 50% of patients may experience recurrence of significant symptoms by 5 years and require further management. The durability appears broadly similar between the two modalities, though head-to-head long-term data are not available. Given the chronic and relapsing nature of gastroparesis, continued follow-up and supportive care are important regardless of the initial procedure. Future studies will clarify which factors (e.g., underlying neuropathy in diabetes) predict sustained response or relapse after pyloric therapies.

 

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Cost-Effectiveness Considerations

Cost-effectiveness is an important practical aspect when comparing an endoscopic procedure to surgery. Several analyses have addressed costs of G-POEM versus pyloroplasty, and while detailed cost-effectiveness modeling is complex, the consensus is that G-POEM tends to be less costly largely due to shorter hospital stays and procedure times. There are no Indian studies to get reference values, hence the indicative costs are given in US dollars. Key points include the following:

• Procedure and hospital costs: G-POEM is typically performed in an endoscopy unit or hybrid operating room (OR), whereas pyloroplasty involves an OR and potentially longer perioperative care. A prior analysis cited in Aziz et al showed that G-POEM had a 26% lower procedural cost than surgical pyloroplasty.[3] This likely reflects savings in OR time, anesthesia, and the lack of surgical disposables. Moreover, the overall cost of care (including hospitalization) is lower for G-POEM: by reducing hospital stay by 3 days, G-POEM avoids substantial room and nursing costs. Aziz et al's meta-analysis argues that these factors make G-POEM a more cost-effective approach for refractory gastroparesis, assuming similar efficacy.

• Illustrative data: in one institution's cost analysis, the direct surgical cost of a robotic pyloroplasty was about $500 higher than a laparoscopic pyloroplasty, but total in-patient costs were similar due to a slightly shorter LOS with robotics.[17] Extrapolating to G-POEM, with an even shorter LOS, one would expect total costs to be equal or lower than laparoscopy. While absolute dollar figures vary, the trend is consistent. For example, if a typical laparoscopic pyloroplasty admission costs approximately $10,000, a G-POEM might cost only approximately $7,000 to $8,000 in total. In Aziz et al's study, the mean differences—approximately 60 minutes less and 3 days less for G-POEM—were statistically significant and likely translate into thousands of dollars saved per case.

• Follow-up costs: another aspect of cost-effectiveness is whether one procedure leads to more downstream costs (e.g., due to complications or re-interventions). In this regard, G-POEM's lower complication rate is advantageous—fewer complications mean fewer interventions or readmissions. The meta-analysis reported no significant difference in 30-day readmission rates between G-POEM and surgery, indicating both are similar in short-term follow-up needs. Re-interventions for recurrent symptoms (like repeat G-POEM or subsequent surgery) could add cost on the long horizon, but these scenarios apply to a minority of patients and are not clearly different between the two approaches.

• Quality of life and indirect costs: a complete cost-effectiveness analysis would incorporate quality-adjusted life years (QALYs) gained from symptom improvement. Although formal QALY analyses are not yet published for G-POEM versus pyloroplasty, the similar efficacy means the quality-of-life gains are comparable. Thus, the procedure with lower costs (G-POEM) would yield a better cost-per-QALY in theory. Additionally, the faster recovery with G-POEM means patients can resume work and daily activities sooner, reducing indirect costs (lost productivity). For working-age patients, avoiding a surgical convalescence of 2 to 4 weeks might be economically significant.

• Device and personnel costs: G-POEM does require specialized endoscopic expertise and equipment (e.g., endoscopic knives, cap, CO₂ insufflator), but these costs are relatively minor compared with a surgical OR. Pyloroplasty might involve costly staplers if done via a robotic platform (though most use hand-sewn technique). One study noted the higher operative expense of robotics did not increase total cost due to offsetting shorter LOS.[17] G-POEM uses standard endoscopy tools with a few disposable accessories, making its supply cost low. The biggest “cost” is the learning curve—endoscopists must be skilled in submucosal endoscopy, which is a limited resource. However, as more centers adopt G-POEM, economies of scale and proficiency may further reduce procedure times and costs.

In summary, G-POEM appears to be more cost-effective than surgical pyloroplasty for refractory gastroparesis, given equivalent efficacy. It incurs lower direct costs (shorter OR time, fewer resources) and especially lower hospitalization costs (often just 1 day vs. 3–4 days). One analysis estimated approximately 25 to 30% cost reduction with G-POEM compared with surgery.[3] These savings do not even account for the intangible benefits of quicker recovery. Thus, from a health economics standpoint, G-POEM may be the preferred first-line pyloric intervention, reserving surgery for those who either do not respond or are not candidates for endoscopy. That said, local costs and expertise can vary—in some health care systems, surgical time might be less costly than advanced endoscopy time, and individual patient factors (such as needing concurrent surgeries) could sway the equation. Overall, however, as multiple authors conclude, the less invasive approach likely confers a cost advantage without sacrificing efficacy

 

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Conclusion

G-POEM and surgical pyloroplasty have revolutionized the management of refractory gastroparesis by directly addressing pyloric dysfunction. Over the past 10 years, accumulating evidence from comparative studies, meta-analyses, and case series indicates the following:

• Efficacy: G-POEM and pyloroplasty provide comparable rates of symptom relief across all major gastroparesis etiologies, with approximately 70 to 80% of patients achieving significant improvement in symptoms (GCSI) and gastric emptying in the short term. Neither modality shows a clear superiority in overall efficacy, and both benefit idiopathic, diabetic, and post-surgical subgroups.

• Symptom and emptying outcomes: both procedures significantly reduce symptom severity and improve quality of life. Average GCSI scores drop by 1.5 to 2 points after treatment, and 4-hour gastric retention typically decreases substantially (often into the normal range in a majority of patients). Head-to-head comparisons reveal no statistically significant differences in final symptom indices or gastric emptying results between G-POEM and pyloroplasty.

• Safety: G-POEM is at least as safe as, and often safer than, surgical pyloroplasty. It is associated with lower complication rates (on the order of 5–15% vs. 10–20% for surgery) and its complications are generally mild. Surgical pyloroplasty is also quite safe in experienced hands, with low rates of serious events (e.g., leak −1%). Neither approach has significant long-term adverse sequelae reported.

• Perioperative recovery: G-POEM offers clear advantages in operative time, hospital stay, and recovery profile. Patients treated with G-POEM can expect a minimally invasive experience, often resuming normal diet and activities within days, whereas surgical patients have a brief hospital convalescence. These differences make G-POEM appealing as a first-line interventional therapy.

• Long-term durability: both interventions can provide sustained relief, though a portion of patients will have recurrence of symptoms over time. At 2 to 3 years, approximately 60 to 70% of initial responders remain improved for both G-POEM and pyloroplasty. Some patients may require repeat or additional therapies in the long run, reflecting the chronic nature of gastroparesis rather than a failure of the procedure per se.

• Cost-effectiveness: G-POEM likely confers a cost benefit due to less resource utilization (shorter OR time, shorter LOS) From a health system perspective, an endoscopic approach may reduce costs by roughly 25% relative to surgery while delivering equivalent outcomes.

In conclusion, G-POEM has emerged as an effective and less invasive alternative to surgical pyloroplasty for refractory gastroparesis, with similar clinical efficacy and potentially superior safety/cost profiles. High-quality evidence, including meta-analyses and multicenter studies, supports the use of G-POEM across gastroparesis etiologies as a treatment that can significantly improve symptoms and gastric emptying. Surgical pyloroplasty, meanwhile, remains a highly effective therapy with a long track record, and it is a crucial option for patients who are not candidates for G-POEM or who prefer a surgical approach. It also serves as a fallback if G-POEM fails, without compromising surgical outcomes.

Going forward, randomized trials (ideally comparing G-POEM to pyloroplasty or to sham) would further strengthen the evidence base, and ongoing research may identify patient factors predicting better response to one or the other. For now, the choice between G-POEM and pyloroplasty can be individualized. Factors such as patient comorbidities, anatomy (prior surgeries that may affect endoscopic access or laparoscopic adhesions), local expertise (availability of advanced endoscopy vs. foregut surgery specialists), and patient preference should guide decision-making. In a tertiary care setting with both options available, many experts propose trying G-POEM first given its minimally invasive nature and repeatability. If symptoms resolve, the patient is spared an operation; if not, surgical pyloroplasty can be pursued with little downside.

Ultimately, the advent of pylorus-directed therapies has markedly improved the outlook for patients with refractory gastroparesis. Whether via an endoscope or a scalpel, tailoring treatment to reduce pyloric resistance offers significant symptomatic relief, improved gastric emptying, and better quality of life for a condition that was once exceedingly difficult to manage. Both G-POEM and surgical pyloroplasty will continue to play central roles in the multidisciplinary management of gastroparesis, and ongoing comparative research will further refine their use in clinical practice.

 

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Conflict of Interest

None declared.

Authors' Contributions

Z.S.: conception of the idea, preparation of manuscript, review of the final draft, and approval.

S.S.: preparation of manuscript, editing of the draft, and final approval

N.C.: preparation of manuscript, editing the draft, and final approval

B.R.: preparation of manuscript, editing the draft, and approval

G.C.: review of manuscript, editing the draft, and approval

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Publikationsverlauf

Artikel online veröffentlicht:
08. August 2025