S1149 A Wrinkle in the Plan: Pyloric Botox May Complicate Eventual G-POEM

Introduction: Pyloric directed therapies including pyloric Botox injection or gastric peroral endoscopic myotomy (G-POEM) can benefit some patients with refractory gastroparesis. With the increase in use of G-POEM among these patients, we aim to evaluate how prior pyloric Botox injections may impact G-POEM outcomes. Methods: We conducted a retrospective review of patients who underwent G-POEM at our institution between April 2019 and 2025. We collected demographic information and details of prior treatments including the number of prior Botox injections. G-POEM procedural details collected included total procedure time, time from incision start to closing end, and time spent on tunneling, myotomy, and closing. Patients were grouped based on how many prior Botox injections they had received. Welch’s t-tests were performed to evaluate differences in procedural times between groups. Results: A total of 50 patients underwent G-POEM during our study period. The majority (N = 42, 84.0%) of patients had prior pyloric Botox injections. Of these, most (73.8%) were women and had idiopathic gastroparesis (64.0%). All procedures were technically successful and there were no complications. Patients were divided into 2 groups, those with 0-1 prior pyloric injections and those with at least 2 prior injections. Patients with 2+ prior injections had a significantly longer average total procedure time compared to those with 0-1 (67.94 vs 56.11 minutes respectively, P = 0.040). A total of 35 patients had full procedural timing details available. When comparing groups in this subset, patients with 2+ prior injections had significantly longer procedure components compared to those that had 0-1 prior injections, including longer average closing time (16.16 vs 10.43 minutes, P = 0.01) and longer average time from incision start to closure end (52.60 vs 36.86 minutes, P = 0.001). There was a trend towards significance with the 2+ prior injection group having a longer average tunneling time compared to those with 0-1 injections (21.28 vs 16.14 minutes, P = 0.07). Conclusion: Our results identified a new consideration in the risk-benefit evaluation of pyloric Botox injections in patients with refractory gastroparesis. Among patients undergoing G-POEM, having repeated Botox injections to the pylorus is associated with longer procedural times. We hypothesize that this may be due to increased fibrosis from repeated instrumentation, which then complicates certain aspects of the procedure and overall procedure time.