Title: Comparative Effectiveness of G-POEM for Post-Esophagectomy Gastroparesis Versus Other Post-Surgical Etiologies

Authors: Andrew Conner MD, Monisha Sudarshan MD, Sudish C Murthy MD, PhD, Siva Raja MD, PhD Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic

Background

• Gastroparesis affects 10–50% of patients after esophagectomy, driven by multifactorial and incompletely understood mechanisms including vagal denervation & functional pyloric obstruction
• Most perform prophylactic pyloric drainage at esophagectomy; no consensus on optimal approach — pyloroplasty, pyloromyotomy, and Botox each carry distinct tradeoffs
• G-POEM is an effective treatment for refractory post-surgical gastroparesis, serving as a rescue option for post-esophagectomy patients who fail prophylactic drainage
• Outcomes of G-POEM in this physiologically distinct population remain poorly defined

Methods

• Single-center retrospective cohort, Cleveland Clinic, January 2017–April 2024
• 55 patients: post-esophagectomy (n=21) vs. other surgical etiologies (n=34)
• Other surgical: Hiatal hernia repair (HHR) with fundoplication (70.6%), HHR without fundoplication (14.7%), Heller myotomy (14.7%)
• Clinical success: ≥0.5-point GCSI reduction
• GES: 4-hour solid-phase scintigraphy

Baseline Characteristics

Pyloric drainage at esophagectomy: pyloromyotomy (57.1%), pyloroplasty (23.8%), botulinum toxin (4.8%), none (9.5%)

Botox Before G-POEM

• Botox administered prior to G-POEM to confirm absence of dumping syndrome before committing to myotomy: 95.2% of post-esophagectomy vs. 82.4% of other surgical patients (P=.232)
• Symptomatic response: 100% of post-esophagectomy vs. 66.7% of other surgical patients (P=.006)

Procedural Outcomes

• Procedure time: 34.0 vs. 35.5 min (post-esophagectomy vs. other surgical, P=.287)
• One postoperative contained leak in post-esophagectomy group; no complications in other surgical group
• Length of stay: 1 day both groups (P=.776)

Clinical Outcomes

• Clinical success: 72.7% post-esophagectomy vs. 76.2% other surgical
• GCSI Total Score (before vs. after G-POEM): Post-esophagectomy 2.1 → 0.9; Other surgical 2.6 → 1.1

Gastric Emptying Outcomes

• Gastric retention at 4 hours (before vs. after G-POEM): Post-esophagectomy 44.0% → 35.0%; Other surgical 42.5% → 9.5%
• GES normalization: 30.8% vs. 50.0% (P=.324)

Conclusions

• G-POEM achieves equivalent clinical success in post-esophagectomy gastroparesis compared to other surgical etiologies, with significant improvement in nausea/vomiting and postprandial fullness in both groups
• Botox should be administered prior to G-POEM to exclude dumping syndrome; universal symptomatic response in post-esophagectomy patients warrants prospective evaluation of Botox as a formal selection criterion
• Symptom-emptying discordance in post-esophagectomy patients likely reflects altered conduit anatomy & physiology — standard scintigraphy may underestimate the functional benefit of myotomy in this population
• These findings support G-POEM as a safe and effective rescue therapy for post-esophagectomy gastroparesis following prophylactic pyloric drainage, providing rationale for a more selective and temporary drainage strategy at esophagectomy