Gastric Peroral Endoscopic Myotomy Versus Botulinum Toxin Injection for the Treatment of Refractory Gastroparesis

Introduction: Gastroparesis (GP) is a chronic gastrointestinal motility disorder that imposes a substantial clinical and economic burden. For patients with refractory GP, gastric peroral endoscopic myotomy (G-POEM) and botulinum toxin injection (BTI) are emerging therapies with differing efficacy profiles and procedural costs. Given these differences, we evaluated the cost-effectiveness of G-POEM versus BTI for refractory GP. Methods: We conducted a cost-effectiveness analysis using a decision tree model informed by randomized trial data from a US health care system perspective over 3- and 12-month time horizons. Procedural costs, adverse events, and repeat BTI sessions were incorporated. Quality-adjusted life-years (QALYs) were estimated from the Gastrointestinal Quality of Life Index (GIQLI) and from Short Form-12 (SF-12) scores. Cost-effectiveness was assessed using incremental cost-effectiveness ratios (ICERs) at a willingness-to-pay (WTP) threshold of $100,000/QALY. Results: The base-case analysis was modeled on a 48.1-year-old patient with refractory GP—defined as persistent symptoms despite 6 months of medical therapy and a GP Cardinal Symptom Index score >2. At 3 months, G-POEM was associated with higher costs and marginally greater effectiveness than BTI (ICER $288,341/QALY), making BTI the cost-effective strategy in the short term. At 12 months, incorporating repeat BTI, G-POEM became the cost-effective option, with BTI yielding an ICER of $334,046/QALY relative to G-POEM. Sensitivity analyses identified clinical success rates and procedural costs as primary cost-effectiveness drivers. At 12 months, the cost-effectiveness acceptability curve showed G-POEM was cost-effective in most simulations at lower WTP thresholds, with BTI favored only at thresholds near $335,000/QALY. Conclusion: While BTI is more cost-effective in the short term, the cumulative costs of repeat sessions make G-POEM the more economically favorable strategy over 12 months. Improving clinical success rate by optimizing patient selection and refining procedural techniques could further improve cost-effectiveness profiles.