Surgical management of Gastroparesis: An Algorithmic Approach

Gastroparesis is a chronic dysmotility disorder defined by delayed gastric emptying in the absence of mechanical obstruction. Management involves a multidisciplinary approach. Available guidelines do not provide much clarity on surgical management of gastroparesis. Thus, the goal of our study was to develop an algorithm for surgical management. Upon evaluation, surgeons may determine which, if any, tests should be repeated. Our current practice is to repeat upper endoscopy with pyloric dilation to assess the need for pyloric intervention. We proceed with pyloroplasty if there is significant improvement and avoid it if symptoms worsen. In equivocal cases, we proceed with botulinum toxin injection along with pyloric dilation. If symptoms persist, we discuss additional options such as gastric electrical stimulation, pylorus directed therapies (gastric peroral endoscopic myotomy or pyloroplasty), or a combined approach. In refractory cases, gastric bypass is considered. Overall, we aim to provide a surgical algorithm for the management of gastroparesis refractory to medication and lifestyle modification.