Gastric per-oral endoscopic myotomy for gastroparesis: a narrative evidence-based review

Background and Objective: Gastroparesis is a gastrointestinal condition characterized by delayed gastric emptying in the absence of overt mechanical obstruction. Gastric peroral endoscopic myotomy (G-POEM) has emerged as a promising minimally invasive endoscopic option for the management of refractory gastroparesis. There is still uncertainty regarding appropriate candidate selection for G-POEM, comparative effectiveness by etiology, peri-procedural standard of practice, and post-procedural care. We aimed to perform a literature review to synthesize efficacy, safety, and durability across etiologies. Additionally, we examine the roles of Gastroparesis Cardinal Symptom Index (GCSI), gastric emptying studies, and endoluminal functional lumen imaging probe (EndoFLIP) in selection and response assessment. We aim to position G-POEM within a practical management algorithm. Finally, we highlight key areas for further study, including predictors of success and strategies for recurrence. Methods: A detailed literature search of various databases was performed, including PubMed, Embase (Embase.com, Elsevier), Web of Science Core Collection, and the Cochrane Database from inception to April 16, 2025. There was no restriction on publication language in the search. The search included keywords and database-specific subject terms gastroparesis, delayed gastric emptying, and G-POEM. A total of 1,256 articles were obtained and manually screened for applicability. A total of 22 articles were obtained to provide an evidence-based review on G-POEM in the management of gastroparesis. Key Content and Findings: G-POEM has emerged as a minimally invasive and safe therapeutic option for refractory gastroparesis, demonstrating near-universal technical success, substantial symptom improvement, and reductions in gastric emptying times. Optimal outcomes are more likely in patients with non-diabetic etiology, shorter symptom duration, lower body mass index (BMI), and prior response to intrapyloric botulinum toxin. EndoFLIP can aid in patient selection and procedural confirmation, though standardized thresholds remain undefined. Comparative studies suggest efficacy comparable to surgical pyloroplasty with shorter recovery, but cost-effectiveness and long-term durability require further investigation. Conclusions: G-POEM significantly improved symptoms, increased quality of life, and reduced health care utilization for patients with gastroparesis.