Which is better for gastroparesis: POP or G-POEM vs Laparoscopic Pyloroplasty?

Gastroparesis is a poorly understood disease that results from inflammation damaging nerves and muscles in the stomach and pylorus. The stomach builds up under pressure to create fullness and bloating. The vagus nerve becomes activated by this increased pressure to send nausea signals to the brain and trigger vomiting. When the stomach becomes tightly distended, blood flow to the stomach muscles is decreased and causes upper abdominal pain. Our blog post explores how the pylorus contributes to gastroparesis and how pyloric therapies can relieve symptoms.

The purpose of the pylorus is to regulate stomach emptying. It is a sphincter muscle at the end of the stomach that opens and closes. It stays closed to keep solid food in the stomach while getting liquified. It then opens to let liquified food empty into the small intestine. With gastroparesis, the nerves signaling the pylorus to open are damaged. This leaves the pylorus closed, preventing the stomach from emptying. Ongoing inflammation replaces the muscle with scar called fibrosis to create a blockage. The purpose of pyloric therapies, including POP or G-POEM and pyloroplasty, is to decompress the stomach and alleviate symptoms by opening the pylorus.

POP (per oral pyloromyotomy) and G-POEM (gastrointestinal peroral endoscopic myotomy) are the same procedure. They involve passing an endoscope down the mouth and through the stomach to divide the pyloric muscle fibers without separating them (pyloromyotomy not pyloroplasty). This can be effective for muscle spasm but not fibrosis. After POEM was seen effective for achalasia in the esophagus, it was then applied as G-POEM to the pylorus for gastroparesis. However, there is a key difference between achalasia and gastroparesis. With achalasia obstruction is caused by muscle spasm, whereas with gastroparesis the obstruction is more often caused by fibrosis. This may explain why POEM is more effective for achalasia than G-POEM is for gastroparesis.

Laparoscopic pyloroplasty is equally effective for muscle spasm and fibrosis and therefore more effective than G-POEM. It cuts through the end of the stomach, across the pylorus, and into the first part of the small intestine. The two ends of the pylorus are pulled apart and the stomach is sewn to the small intestine in between, so the pylorus cannot close back down. This is unlike G-POEM where the divided muscle can scar back together. At Vanguard Surgical, we have performed numerous successful pyloroplasties on patients with failed G-POEM. Therefore, we believe G-POEM should be reserved for patients that are not candidates for pyloroplasty or if pyloroplasty is not available in your area as an outpatient, home same day, procedure by a surgeon with <1.0% leak rate.