Pyloric-directed therapy for gastroparesis: to cut or to relax?

In this issue of Endoscopy, Gonzalez et al. present the first double-blind randomized controlled trial to compare the efficacy of gastric peroral endoscopic myotomy (G-POEM) versus botulinum toxin injection (BTI) for the treatment of refractory gastroparesis [1]. Gastric peroral endoscopic myotomy (G-POEM) was first introduced in 2013 as an alternative option for patients with refractory gastroparesis [2]. Recently, two clinical trials, a large multicenter prospective trial by Vosoughi et al. [3] and a randomized sham-controlled trial by Martinek et al. [4], have evaluated the use of G-POEM in refractory gastroparesis and demonstrated a clinical success rate of 56%–70% at 12 months, with low rates of adverse events. Despite these promising results, G-POEM remains a technically challenging procedure, available only in expert centers, while BTI is widely available. Previously no study had directly compared the two endoscopic pylorus-directed therapies.