Management of failed pyloric drainage procedures in patients with gastroparesis

BACKGROUND: Laparoscopic pyloroplasty and gastric peroral endoscopic myotomy (G-POEM) relieve symptoms in most patients with refractory gastroparesis (GP). However, approximately 28% of patients who underwent pyloroplasty and an estimated 13% of patients who underwent G-POEM per year experience primary or secondary failure. Evidence-based guidance on what to do next is lacking. This study aimed to synthesize current data on the evaluation and treatment of patients with GP after failed pyloric drainage and propose a pragmatic, algorithm-oriented pathway for multidisciplinary care. METHODS: A structured narrative review was conducted by searching PubMed, Embase, and Cochrane databases for English-language literature (January 2000-July 2025) using keywords, such as "gastroparesis," "pyloroplasty," "G-POEM," "gastric electrical stimulation," and "gastrectomy," combined with "failure" or "recurrence." More than 40 pertinent studies were selected based on relevance to the postpyloric intervention setting. Predictors of failure, diagnostic strategies, and salvage interventions were extracted and integrated into tables and an illustrative algorithm. RESULTS: Clear definitions of clinical and objective failure are essential but heterogeneous across studies. Predictors of poor outcome include younger age, higher baseline Gastroparesis Cardinal Symptom Index, longer disease duration, higher body mass index, psychiatric medication use, and persistent postprocedure gastric retention. Postfailure management begins with confirmation of failure, medication/diet optimization, and repeat endoscopy and gastric emptying scintigraphy. Endoluminal functional lumen imaging probe or antroduodenal manometry may refine phenotyping. Salvage options are tailored to physiology and symptom profile: redo G-POEM for suspected technical recurrence, gastric electrical stimulation for persistent nausea and vomiting, jejunostomy with venting gastrostomy for severe malnutrition, and, for the most refractory cases, Roux-en-Y gastric bypass or near-total gastrectomy, each with distinct risk-benefit profiles. An evidence-based decision tree is provided to support shared decision-making. CONCLUSION: Failed pyloric drainage underscores the complex, multimechanistic nature of GP. A structured algorithm that blends symptom assessment, objective testing, and staged interventions can individualize care while highlighting gaps - namely, standardized failure criteria and comparative effectiveness trials - that warrant future research.