PREDICTORS OF FAVORABLE OUTCOME AFTER PYLOROPLASTY FOR GASTROPARESIS: SHOULD RESPONSE TO PYLORIC DILATION OR BOTOX INJECTION BE USED AS A MARKER OF SURGICAL OUTCOME?
Sven Eriksson*1, Scott Morton1, Ping Zheng2, Margaret Riccardi1, Nicole Maurer1,2, Toshitaka Hoppo1, Blair Jobe1,2, Shahin Ayazi1,2
1Allegheny Health Network, Pittsburgh, PA; 2Drexel University, Philadelphia, PA
Introduction:
Pyloroplasty and gastric-per oral endoscopic myotomy (G-POEM) are effective surgeries for gastroparesis. The primary aim of this study was to evaluate outcomes of pyloroplasty and G-POEM in patients with gastroparesis and to determine factors associated with a favorable outcome. The secondary aim was to assess the utility of clinical response to pre-operative pyloric dilation or dilation with concurrent botulinum toxin injection (Botox) on surgical outcome, a factor conventionally used as a favorable marker in patient selection, despite lack of evidence.
Material and methods:
There were 204 patients who underwent pyloroplasty (n=177) or G-POEM (n=27) for gastroparesis at our institution over an 8 year period. Age, etiology of gastroparesis (idiopathic, diabetic, post-surgical), concomitant GERD, and primary symptom (nausea/vomiting, bloating, abdominal pain) were factors analyzed for impact on surgical outcome. To assess whether pyloric dilation or Botox injection impacts surgical outcome, a subgroup of patients who had these pre-operative interventions were assessed separately. Favorable outcome was defined as patient reported improvement and resolution of primary gastroparesis symptoms.
Results:
Favorable outcome was achieved in 78.4% of all patients (pyloroplasty: 79.7% and G-POEM: 70.4%, p= 0.274). In a subset of 61 patients where pre- and post-surgery gastric emptying studies (GES) were available, mean percent retention at 4-hours significantly improved from 33.5 to 15.0 (p<0.001) and normalization of GES was achieved in 77.0% of patients.
Favorable outcome was not significantly impacted by etiology of gastroparesis (idiopathic vs. diabetic vs. post-surgical, p=0.120), concomitant GERD (p=0.518) or primary gastroparesis symptom (nausea/vomiting vs. bloating vs. abdominal pain, p=0.244). Age ?40 was the only significant predictor of favorable surgical outcome on univariate and multivariate analysis [OR: 2.476 (1.224 – 5.008), p=0.012].
In the subgroup of patients who had pre-operative dilation (n=82) or Botox injection (n=46), response to these interventions was not a predictor of favorable surgical outcome (p=0.192 and 0.979, respectively). However, those who had Botox injection prior to surgery, regardless of response to injection, had a higher likelihood of a favorable surgical outcome [OR: 3.205 (CI 1.105 – 9.299), p=0.032].
Conclusion:
Symptomatic improvement after pyloroplasty or G-POEM is independent of etiology of gastroparesis, presence of concomitant GERD and primary symptom. Response to dilation or Botox are not markers of response to surgery. However, patients who receive Botox are 3.2-times more likely to improve after pyloroplasty or G-POEM.
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