Gastric peroral endoscopic myotomy for compassionate treatment of symptomatic gastroparesis in patients on chronic opioids

It has been estimated that nearly half of patients with gastroparesis use opioids long term, are unable to cease or wean opioid use, and continue to endorse debilitating symptoms. The aim of this study was to evaluate outcomes of gastric peroral endoscopic myotomy (G-POEM) as compassionate treatment in patients with gastroparesis who are unable to discontinue long-term opioid use. This was a multicenter retrospective analysis of prospective databases containing patients with gastroparesis taking opioids who underwent G-POEM between January 2021 and November 2024. Functional luminal imaging probe (FLIP) pyloric measurements were obtained pre- and post-G-POEM at follow-up. Clinical response to G-POEM was defined as improvement of ≥1 point on the Gastroparesis Cardinal Symptom Index. Thirty-eight patients with gastroparesis on opioids with a median follow-up of 6 months (range, 3-18 months) underwent G-POEM during the study period. Technical success was 100%. Clinical success was achieved in 60.5% (23/38) of the patients. There were no differences in demographics, symptom duration, etiology of gastroparesis, baseline Gastroparesis Cardinal Symptom Index score, gastric-emptying scintigraphy or daily morphine milligram equivalent between responders and nonresponders. When compared with nonresponders, patients who responded to G-POEM had a significantly lower FLIP baseline pyloric diameter (13.2 [standard deviation (SD) 3.4 mm 2 ] vs 15.6 [SD 2.7 mm 2 ]; P = .04) and distensibility index (4.8 [SD 1.9 mm 2 /mm Hg] vs 8.4 [SD 4.6 mm 2 /mm Hg]; P = .004). Clinical response was associated with improvement in FLIP pyloric diameter and distensibility index. This study suggests that G-POEM could be considered as a safe and effective compassionate treatment in select patients with gastroparesis who are taking opioids long term, particularly those with lower pyloric compliance on physiologic testing. Future studies are needed to corroborate these preliminary findings.