Pyloric interventions such as pyloroplasty and pyloromyotomy are other surgical treatment modalities offered for gastroparesis. Whereas GES uses neurostimulation to facilitate gastric emptying and potentially improve fundic accommodation, pyloric interventions are intended to increase gastric emptying by reducing outflow resistance from the pyloric sphincter.
Pyloric Interventions
Various studies have shown significant improvements with pyloric interventions, similar to the improvements seen with GES. One such study involving 177 patients demonstrated an 86% improvement in gastric emptying, with symptom severity scores for nausea, vomiting, bloating, abdominal pain, and early satiety decreasing significantly at 3 months following pyloroplasty.67 A significant advantage of pyloric interventions is that pyloromyotomy can be performed endoscopically (gastric peroral endoscopic pyloromyotomy [G-POEM] or peroral pyloromyotomy [POP]), thus minimizing the risks of open surgery. A recent review that included a pooled analysis of 7 studies of G-POEM for gastroparesis demonstrated 100% technical success, with clinical efficacy in 81.5% of the procedures as assessed by the GCSI.68 Additionally, the intraoperative and perioperative complication rates were 6.6% and 7.6%, respectively, suggesting that G-POEM is a safe and clinically beneficial therapeutic option. Few studies comparing the outcomes of pyloric interventions to GES have been performed.
Recently, GES has been combined with pyloric interventions to maximize therapeutic potential. This allows simultaneous neurologic and functional interventions to expedite gastric emptying and improve patient symptomatology. Davis et al demonstrated significant improvement in 21 patients who underwent GES placement and pyloroplasty, with 71% improvement in total symptom severity.69 Notably, dual surgery did not increase the incidence of infection or adverse surgical outcomes. Although this study did not directly compare dual surgery to GES alone, the results are nonetheless favorable. GES provides a strong antiemetic and anti-nausea effect, whereas the pyloromyotomy provides improvement in gastric emptying.
Feeding/Venting Tubes
Feeding jejunostomy tubes and venting gastrostomy tubes can be used alone or in combination with GES. Feeding jejunostomy is performed for malnutrition and weight loss that accompanies the refractory symptoms of early satiety, nausea, and vomiting. Venting gastrostomy tubes allow for removal of retained gastric contents that may cause distension, nausea, and vomiting. Gastrojejunostomy tubes can also be placed endoscopically or by interventional radiology.
Gastrectomy
Gastrectomy can provide therapeutic benefit through elimination of the gastric reservoir function and consequent removal of afferent neural impulses. In select patient populations, outcomes of gastrectomy have compared favorably with those of GES. For example, one study demonstrated favorable outcomes of Roux-en-Y gastrectomy in morbidly obese patients with gastroparesis.70 In another study, favorable outcomes were reported in a cohort of 103 patients, with gastrectomy demonstrating 87% symptom improvement (nausea, vomiting, epigastric pain) compared to just 63% improvement with GES.71 However, the dramatic impact on anatomy and physiology and the invasiveness of the procedure need to be weighed against the therapeutic benefit. For example, in the same study, the 30-day morbidity was 23% for gastrectomy versus just 8% for the GES implant.71
