Surgical Treatment for Refractory Gastroparesis: Stimulator, Pyloric Surgery, or Both?

  • Bryan Zoll
  • Asad Jehangir
  • Michael A. Edwards
  • Roman Petrov
  • William Hughes
  • Zubair Malik
  • Henry P. ParkmanEmail author
Original Article



Several surgical options exist for refractory gastroparesis (Gp) including gastric electric stimulation (GES) and pyloric surgery (PS) such as pyloromyotomy or pyloroplasty. Few studies exist comparing the outcomes of these surgeries.


Compare the clinical outcomes of GES, PS, and simultaneous GES+PS for refractory Gp.


Patients undergoing surgical intervention at our medical center from January 2016 to April 2019 were given pre- and post-surgery questionnaires to assess their response to intervention: Patient Assessment of Upper Gastrointestinal Symptoms (PAGI-SYM) grading symptoms and Clinical Patient Grading Assessment Scale (CPGAS) grading response to treatment. Results are expressed as mean ± SE.


One hundred thirty-two patients underwent surgical intervention; 12 were excluded. Mean CPGAS improvement overall was 2.8 ± 0.2 (p < 0.01): GES+PS had CPGAS score at 3.6 ± 0.5, pyloric interventions 3.1 ± 0.5, and GES 2.5 ± 0.4 (p > 0.05). Mean improvement in Gastroparesis Cardinal Symptom Index (GCSI) total score was 1.0 ± 0.1 (p < 0.01), with improvement of 1.1 ± 0.2 for GES + PS, 0.9 ± 0.2 for GES, and 0.9 ± 0.2 for PS (p > 0.05). GES and GES + PS, but not PS only, significantly improved symptoms of nausea and vomiting (p < 0.01). Among gastroparesis subtypes, patients with diabetic gastroparesis had more improvement on nausea/vomiting subscale compared with idiopathic gastroparesis (p = 0.028).


Patients with refractory symptoms of Gp undergoing GES, PS, or combined GES+PS each had significant improvement of their GCSI total score. GES and combined GES+PS significantly improved nausea/vomiting. These results suggest GES or combined GES+PS appears better for nausea/vomiting predominant refractory Gp.


Gastroparesis Gastric electric stimulation Pyloroplasty Pyloromyotomy 


Authors Contributions

Bryan Zoll, MD, MBA: data acquisition, data interpretation, drafting and revising manuscript.

Asad Jehangir, MD: data acquisition, data interpretation, drafting and revising manuscript.

Michael A. Edwards, MD: study concept, surgical procedures, revising manuscript.

Roman Petrov, MD, PhD: surgical procedures, revising manuscript.

William Hughes, MD: surgical procedures, revising manuscript.

Zubair Malik, MD: drafting and revising manuscript.

Henry P. Parkman, MD: study concept, patient enrollment, drafting and revising manuscript.

Compliance with Ethical Standards

Enterra gastric electric stimulator (GES) for refractory gastroparesis is approved under the FDA humanitarian device exemption program and approved at our institution by our Institutional Review Board

Conflicts of Interest

The authors declare that they have no conflict of interest.


  1. 1.
    Camilleri M, Parkman HP, Shafi MA, et al. Clinical guideline: management of gastroparesis. Am J Gasterol. 2013; 108:18–37CrossRefGoogle Scholar
  2. 2.
    Dudekula A, O’Connell M, Bielefeldt K. Hospitalizations and testing in gastroparesis. J Gastroenterol Hepatol. 2011;26:1275–1282.CrossRefGoogle Scholar
  3. 3.
    Khashab MA, Stein E, Clarke JO, Saxena P, Kumbhari et al. Gastric peroral endoscopic myotomy for refractory gastroparesis: first human endoscopic pyloromyotomy (with video). Gastrointest Endosc. 2013;78(5):764–768CrossRefGoogle Scholar
  4. 4.
    Sarosiek I, Forster J, Lin Z, Cherry S, Sarosiek J, McCallum R. The addition of pyloroplasty as a new surgical approach to enhance effectiveness of gastric electrical stimulation therapy in patients with gastroparesis. Neurogastroenterol Motil. 2013;25:134–180CrossRefGoogle Scholar
  5. 5.
    Davis B, Sarosiek I, Bashashati M, Alvarado B, McCallum R. The long-term efficacy and safety of pyloroplasty combined with gastric electrical stimulation therapy in gastroparesis. J Gastrointest Surg. 2017;21:222–227CrossRefGoogle Scholar
  6. 6.
    Arthur L, Slattery L, Richardson W. Tailored approach to gastroparesis significantly improves symptoms. Surg Endosc. 2018;32:977–982.CrossRefGoogle Scholar
  7. 7.
    Tougas G, Eaker EY, Abell TL, Abrahamsson H, Boivin M, Chen J, et al. Assessment of gastric emptying using a low fat meal: establishment of international control values. Am J Gastroenterol. 2000;95(6):1456–62.CrossRefGoogle Scholar
  8. 8.
    Rentz AM, Kahrilas P, Stanghellini V, et al. Development and psychometric evaluation of the patient assessment of upper gastrointestinal symptom severity index (PAGI-SYM) in patients with upper gastrointestinal disorders. Qual Life Res. 2004;13(10):1737–49.CrossRefGoogle Scholar
  9. 9.
    Atassi H, Abell TL. Gastric electrical stimulator for treatment of gastroparesis. Gastrointest Endoscopy Clin N Am. 2019; 29:71–83.CrossRefGoogle Scholar
  10. 10.
    Qin C, Chen JD, Zhang J, Foreman RD. Modulatory effects and afferent pathways of gastric electrical stimulation on rat thoracic spinal neurons receiving input from the stomach. Neurosci Res 2007;57;29–39CrossRefGoogle Scholar
  11. 11.
    Abell TL, Van Cutsem E, Abrahamsson H, Huizinga JD, Konturek JW, Galmiche JP, VoelIer G, Filez L, Everts B, Waterfall WE, Domschke W, Bruley des Varannes S, Familoni BO, Bourgeois IM, Janssens J, Tougas G. Gastric electrical stimulation in intractable symptomatic gastroparesis. Digestion. 2002;66(4):204–212.CrossRefGoogle Scholar
  12. 12.
    Abell T, McCallum R, Hocking M, Koch K, Abrahamsson H, Leblanc I, Lindberg G, Konturek J, Nowak T, Quigley EM, Tougas G, Starkebaum W. Gastric electrical stimulation for medically refractory gastroparesis. Gastroenterology 2003;125(2):421–428.CrossRefGoogle Scholar
  13. 13.
    Zhang H, Zhang J, Jiang A, Ni H. Gastric peroral endoscopic myotomy for gastroparesis: A systematic review of efficiency and safety. Gastroenterol Hepatol. 2019 Apr 3. pii: S0210–5705(19)30048–2.Google Scholar
  14. 14.
    Revicki DA, Camilleri M, Kuo B, Norton NJ, Murray L, Palsgrove A, et al. Development and content validity of a gastroparesis cardinal symptom index daily diary. Aliment Pharmacol Ther 2009;15;30(6):670–80.CrossRefGoogle Scholar
  15. 15.
    Maranki JL, Lytes V, Meilahn JE, et al. Predictive factors for clinical improvement with Enterra gastric electric stimulation treatment for refractory gastroparesis. Dig Dis Sci. 2008;53:2072–2078.CrossRefGoogle Scholar
  16. 16.
    Zoll B, Zhao H, Edwards MA, Petrov R, Schey R, Parkman HP. Outcomes of surgical intervention for refractory gastroparesis: a systematic review. J Surg Research. 2018;231:263–269CrossRefGoogle Scholar

Copyright information

© The Society for Surgery of the Alimentary Tract 2019

Authors and Affiliations

  • Bryan Zoll
    • 1
  • Asad Jehangir
    • 1
  • Michael A. Edwards
    • 2
  • Roman Petrov
    • 3
  • William Hughes
    • 1
  • Zubair Malik
    • 1
  • Henry P. Parkman
    • 1
    Email author
  1. 1.Section of Gastroenterology, Department of MedicineLewis Katz School of Medicine at Temple UniversityPhiladelphiaUSA
  2. 2.Department of General SurgeryMayo ClinicJacksonvilleUSA
  3. 3.Department of Thoracic Medicine and SurgeryLewis Katz School of Medicine at Temple UniversityPhiladelphiaUSA

Personalised recommendations