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ObjectiveAlthough gastric per-oral endoscopic myotomy (G-POEM) is considered a promising technique for the management of refractory gastroparesis, high-quality evidence is limited. We prospectively investigated the efficacy and safety of G-POEM in unselected patients with refractory gastroparesis.DesignIn five tertiary centres, patients with symptomatic gastroparesis refractory to standard medical therapy and confirmed by impaired gastric emptying were included. The primary endpoint was clinical success, defined as at least one score decrease in Gastroparesis Cardinal Symptom Index (GCSI) with ≥25% decrease in two subscales, at 12 months. GCSI Score and subscales, adverse events (AEs) and 36-Item Short Form questionnaire of quality of life were evaluated at baseline and 1, 3, 6 and 12 months after G-POEM. Gastric emptying study was performed before and 3 months after the procedure.ResultsOf 80 enrolled patients, 75 patients (94%) completed 12-month follow-up. Clinical success at 12 months was 56% (95% CI, 44.8 to 66.7). GCSI Score (including subscales) improved moderately after G-POEM (p<0.05). In a regression model, a baseline GCSI Score >2.6 (OR=3.23, p=0.04) and baseline gastric retention >20% at 4 hours (OR=3.65, p=0.03) were independent predictors of clinical success at 12 months, as was early response to G-POEM at 1 month after therapy (OR 8.75, p<0.001). Mild procedure-related AEs occurred in 5 (6%) patients.ConclusionG-POEM is a safe procedure, but showed only modest overall effectiveness in the treatment of refractory gastroparesis. Further studies are required to identify the best candidates for G-POEM; unselective use of this procedure should be discouraged.Trial registration numberClinicalTrials.gov Registry NCT02732821.

Although balloon-assisted enteroscopy-endoscopic retrograde cholangiopancreatography (BAE-ERCP) is a well-described means of accessing the duodenal papilla in patients with Roux-en-Y gastric bypass (RYGB), it is associated with modest clinical success rates. Laparoscopy-assisted ERCP (LA-ERCP)—performed by advancing a standard duodenoscope through a gastrostomy into the excluded stomach and duodenum—has emerged as a viable alternative to BAE-ERCP, with apparently higher success rates. In this systematic review, we compare LA-ERCP with enteroscopy-based techniques in post-RYGB patients, including 22 case series that provided data on papilla identification, papilla cannulation, and complications. We found that LA-ERCP was superior to the enteroscopy-based techniques in its capacity to reach the duodenal papilla, although complication rates were lower for the latter. Comparative studies are needed in order to corroborate our findings.