Pyloroplasty After Gastric Electric Stimulation: Does It Help?

Introduction: Gastroparesis (Gp) is a syndrome characterized by delayed gastric emptying (GE) in the absence of mechanical obstruction, and it is associated with symptoms of early satiety, nausea, vomiting, abdominal pain, and bloating. Gastroparesis like syndrome (GLS) is defined as gastroparesis-like symptoms with normal GE. Both Gastric electrical stimulation (GES) and pyloroplasty (PYT) have been shown to improve symptoms in pts. with Gp/GLS. It remains unclear which therapy should be performed first. A systematic way to select pts. for these therapies remains unknown. We aimed to evaluate associations between delayed and non-delayed GE and symptom improvement in pts. with PYT after GES implant. Methods: We evaluated 72 pts. with gastroparesis and gastroparesis like syndrome (GLS). All pts. underwent a trial a GES (temp) for 1 week followed by permanent (perm) GES placement. A GE study using both solid and liquids was performed before GES placement. PYT, either endoscopically or surgical pyloroplasty, was done in pts. with sub-optimal response to Temp and/or Perm GES. Outcomes of vomiting, nausea, abdominal pain, bloating, anorexia, constipation, diarrhea, frequent and in-frequent urination were assessed using FDA complaint TradPRO scale. Student’s t-test evaluated changes in outcomes based on gastric emptying status for continuous variables, while Chi-squared test evaluated categorical variables. Results: Pts. were evaluated for improvement in individual sx. with improvement found only in bloating. In pts. with > 10% solid retention at 4 hours, it was noted that bloating scores improved post PYT (3.19 vs. 2.86), whereas pts. who had non-delayed GE did not find any improvement with PYT (2.71 vs. 3.14). A similar effect was seen in pts. with more than 20% retention at 4 hours (3.16 vs. 2.93) and more than 30% retention (3.15 vs. 2.83). Pts. with non-delayed GE did not have an improvement in bloating with PYT. These values did not reach statistical significance. Conclusion: PYT is an increasingly offered treatment option for pts. with drug and device refractory gastroparesis. Literature is lacking around patient selection and timing of the surgery. Most pts. with delayed GE find initial relief in bloating after GES placement. In some pts., this symptomatic effect starts to subside around 1-year post GES. Based on this study, we observed that PYT could help improve bloating symptoms in pts. with delayed GE with less-than-optimal response of gastric electric stimulation.Figure 1.: Bloating symptom score over multiple timepoints. A) Solid Gastric emptying study with 10% retention at 4 hours B) Solid Gastric emptying study with 20% retention at 4 hours C) Solid Gastric emptying study with 30% retention at 4 hours.Table 1.: Comparison of Bloating Between Delayed and Non-Delayed Gastric Emptying.