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Treatment options
Pyloroplasty
More than 2,000 performed. Outpatient, laparoscopic, home the same day, with a leak rate under half of one percent.
If your stomach feels full and bloated, if it aches, and if the nausea seems to ride on top of all that — the problem may not be that your stomach is slow. It may be that the door at the end of it won’t open.
Pyloroplasty opens that door. It is the operation most Vanguard patients have first, and for roughly two in three, it is the only operation they need.
Dr. Hughes has performed more than 2,000 pyloroplasties. They are done laparoscopically, as outpatient surgery, most often at an ambulatory surgical center. Patients go home the same day.
The pylorus, and why it matters
The pylorus is a ring of muscle at the end of your stomach. Its job is to stay closed while your stomach liquefies solid food, then open to let that liquefied food pass into the small intestine.
In gastroparesis, the nerves that tell the pylorus to open are damaged. The pylorus stays shut. And because the inflammation doesn’t stop, muscle is gradually replaced by scar tissue — fibrosis — until the closure is structural rather than functional.
Everything you feel follows from that.
- Food and swallowed air accumulate, and the stomach distends. That is the fullness and the bloating.
- The stretched stomach wall activates the vagus nerve, which carries nausea signals to the brain and triggers vomiting.
- When the stomach is tightly distended, blood flow to the stomach muscle drops. That is the upper abdominal pain.
It’s a clogged drain. You can’t get the sink to empty by pushing the water through harder. You have to open the drain.
That analogy also explains what doesn’t work. Botox injected into the pylorus relaxes muscle — it does nothing to scar. Prokinetic medications tell the stomach to push harder against a closed door. A gastric stimulator does not open the pylorus at all. If the obstruction is fibrotic, none of them address it.
What the operation does
Pyloroplasty is done through a few small laparoscopic incisions — four, each no wider than a fingertip.
- A stay suture is placed at the top of the pylorus and another at the bottom, and the pylorus is lifted.
- A single cut is made lengthwise — through the end of the stomach, across the pylorus, and into the first part of the small intestine.
- The two cut ends of the pylorus are pulled apart, and the stomach is sewn to the small intestine in between, crosswise to the original cut.
The result is that the two cut ends of the pylorus can never come back together. What was tightly shut is now permanently, widely open.
Mild
Moderate
Severe
Inside the expansion: A normal pylorus is the same thickness as the stomach wall. When Dr. Hughes cauterizes through muscle it chars; where there is fibrosis instead of muscle, the tissue stays white. In a healthy pylorus you see char all the way across. In most gastroparesis patients you don’t — you see a pylorus two, three, or four times the thickness of the stomach wall, much of it pale scar.
He photographs it during every case and shows the patient afterward. Three patients operated on the same day can show three completely different pyloruses, from nearly normal to severely thickened.
Where this operation came from
Pyloroplasty is not new, and it was not invented for gastroparesis.
Decades ago, surgeons treated stomach ulcers by cutting the vagus nerve to reduce acid production. Cutting the vagus nerve had a predictable side effect: the pylorus stopped opening. So every vagotomy was paired with a pyloroplasty to compensate.
Then acid-blocking medications arrived, H. pylori was identified as the cause of most ulcers, and vagotomy — along with pyloroplasty — largely stopped being performed.
Surgeons reintroduced it for gastroparesis because the logic transferred directly: nerve injury, pylorus won’t open, open it surgically. The results were good.
Pyloroplasty vs. G-POEM (POP)
G-POEM and POP are the same procedure under two names. An endoscope is passed through the mouth into the stomach, and the pyloric muscle fibers are divided from the inside.
The difference that matters is what happens to the two ends.
| G-POEM / POP | Laparoscopic pyloroplasty | |
|---|---|---|
| Approach | Endoscopic, through the mouth | Laparoscopic, four small incisions |
| What it does | Cuts the muscle | Cuts the muscle and separates the two ends |
| Works on muscle spasm | Yes | Yes |
| Works on fibrosis | No | Yes |
| Can it close back down | Yes — the divided muscle can scar together | No — the ends are held apart permanently |
G-POEM was adapted from POEM, a procedure that works well for achalasia in the esophagus. But achalasia is a muscle spasm problem, and gastroparesis is more often a scar problem. That difference likely explains why G-POEM has not matched POEM’s results.
Where the guidelines stand. The 2025 American Gastroenterological Association guideline suggests against routine use of G-POEM in medically refractory gastroparesis. On surgical pyloric interventions — pyloromyotomy and pyloroplasty — the AGA makes no recommendation either way, identifying it as a gap in the evidence rather than a settled question. Larger studies are needed, and that is a fair statement of where the field is.
Vanguard has performed many successful pyloroplasties on patients whose G-POEM failed. Having had one does not burn any bridges. But the reverse isn’t true — a pyloroplasty doesn’t need redoing.
Where G-POEM makes sense: patients who can’t have surgery or general anesthesia, and patients without access to an experienced pyloroplasty surgeon.
What a Botox response tells you
If Botox injected into your pylorus helped, that is useful information: it means the pylorus is still muscle in spasm rather than scar. Those patients should respond well to pyloroplasty, and possibly to G-POEM as well.
If Botox did not help, the pylorus may already be fibrotic. Those patients still respond well to pyloroplasty — which cuts through scar — but should not expect G-POEM to work, because G-POEM cuts muscle.
One caution worth knowing before you agree to it: Botox injection can itself provoke inflammation and fibrosis of the pylorus.
Who this operation is for
The decision is made on symptoms. There is no test that settles it.
Callout — why we don’t use Endo-FLIP: Some practices use Endo-FLIP to measure the pylorus and decide whether a pyloric intervention is indicated, or whether one worked. Vanguard doesn’t, for three reasons. The evidence for it is inconsistent in both directions. It was designed for the esophagus, not the pylorus, and the anatomy and mechanics of the two are different. And it can only be done in a hospital setting, which limits who can get it at all.
Is your stomach under pressure?
Pyloroplasty is the right first operation if you have bloating, fullness, and upper abdominal pain alongside the nausea. The pressure is the problem, and decompressing the stomach relieves it.
Pyloroplasty is not the right operation if you have nausea and vomiting without the bloating, fullness, and pain. There’s no pressure to relieve. Those patients go straight to gastric stimulation.
What to expect
Results. Roughly two in three patients improve enough after pyloroplasty that no stimulator is ever needed. About one in three go on to gastric stimulation, usually for nausea that persists after the pressure problem has been solved.
Timeline. Most patients start feeling better within one to two weeks. There are two distinct steps of improvement:
- Month 1 — most of the improvement, as the swelling from surgery subsides
- Month 3 — a second step, when the dissolving suture releases and the opening widens further
The pyloroplasty is not fully open until three months. That is why Dr. Hughes will not consider a gastric stimulator before then.
Diet after surgery. Liquids first, then puréed, then soft foods, advancing to solids as you feel better. Most patients are experimenting with solid food around two weeks. Everyone advances at a different pace.
Activity. Nothing heavier than 10 pounds for two weeks. Showering is fine; don’t submerge the incisions for two weeks. Dressings come off after a week. The stitches are under the skin and dissolve — there’s nothing to remove.
Follow-up. One month and three months, then roughly every three months until things are stable, then yearly. Follow-up visits can be done by telehealth.
Chew, and drink your protein
Opening the pylorus lets food out. It does not restore your stomach’s ability to liquefy it. So your teeth have to do work your stomach used to do — chew thoroughly. And a protein shake with 30–40 grams of protein needs nothing from your stomach at all. One or two a day is worth continuing even after your symptoms improve.
Risks, stated plainly
Leak at the suture line. This is the one that matters. Eight leaks in roughly 2,000 pyloroplasties — under half of one percent. That is lower than published rates for both pyloroplasty and G-POEM/POP.
It typically shows up five to seven days after surgery: you’re improving each day, then you go backwards. Fever, abdominal pain, something clearly wrong. A CT scan shows air and fluid where there shouldn’t be any. Treatment is a drain in the side, antibiotics, and nothing by mouth until it seals — usually a few days to a week. Occasionally it means going back to the operating room.
Patients recover fully, and the pyloroplasty still works. The recovery is just harder.
Dr. Hughes tracked down the cause of his early leaks: a barbed suture whose barbs were sharp enough to tear swollen tissue. He changed sutures. Over the 1,700-plus pyloroplasties since, there have been three leaks.
Abscess from spilled food. Now uncommon. All patients restrict their diet to clear liquids the day before surgery. If your endoscopy showed retained food in the stomach, you’ll do a puréed diet for three days beforehand as well. Between the two, this has largely been eliminated — it happens perhaps twice a year, and is managed with a drain and antibiotics.
Bile reflux pain. Some patients develop a new upper abdominal pain around the one-month mark — distinct from heartburn, felt above the belly button. It’s bile from the small intestine irritating the stomach. Sucralfate usually resolves it by the three-month visit. Fewer than five patients in about 2,000 have needed it long-term.
Needing a stimulator later. About one in three. This isn’t a complication so much as the expected next step for persistent nausea.
What about dumping syndrome?
This is one of the most common questions patients ask, and the answer is that we do not see it in gastroparesis patients after pyloroplasty.
Dumping syndrome is real, and the association with pyloroplasty is real — but it comes from a different operation performed on a different group of people. Decades ago, pyloroplasty was done together with vagotomy to treat non-healing stomach ulcers. Those patients did not have gastroparesis. Their stomachs were otherwise normal and emptying at a normal rate. Open the pylorus on a stomach that already empties normally and it can empty too fast. That is dumping syndrome.
Your stomach is the opposite. It is weak, it is floppy, and it empties too slowly — which is the entire problem.
Emptying faster isn’t the side effect. It’s the goal.
The operation is meant to move a slow stomach toward normal, not to push a normal stomach past it. That is why the complication described in the ulcer literature has not turned out to be a complication here.
Insurance and denials
Denials used to be routine in gastroparesis care. They have become infrequent — but they still happen, and a denial is not the end of the conversation. When a pyloroplasty is denied, Dr. Hughes does the peer-to-peer review himself — physician to physician with the insurer’s reviewer, explaining why this patient needs this operation. If necessary, he can appeal the denial on your behalf.
Patients still arrive having been told no. Often that no can be overturned.
“It’s been a long journey! I haven’t felt this good in the stomach for 5 years! Thank you for fighting the insurance and helping my stomach empty! A life-changing procedure”
— Adrianne, pyloroplasty
“Thank you so much I feel so much better. My life was so miserable and now I feel like I have my life back.”
— Amy, laparoscopic pyloroplasty
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