Gastroparesis is a chronic disorder affecting gastrointestinal motility with a limited response to medication. Recently, endoscopic and surgical procedures have become effective treatment alternatives; however, comparative evidence between different treatment approaches is limited. This study aimed to systematically evaluate and compare the effectiveness of gastric emptying using endoscopic and surgical interventions for the treatment of gastroparesis through a network meta-analysis. The primary objective was to determine which treatment procedure achieves the greatest improvement in symptoms and gastric motility, thereby guiding the selection of the optimal treatment for patients with treatment-resistant gastroparesis.

We searched the PubMed, Embase, and CENTRAL databases for studies published between January 2000 and the present. Eligible studies included randomized controlled trials and observational analyses involving adult patients diagnosed with gastroparesis who underwent procedural interventions. Treatments included gastric peroral endoscopic myotomy (GPOEM), gastric neuronal stimulation, pyloroplasty (GNS), botulinum toxin injection (BTI), and combination therapies such as G-POEM + GES or pyloroplasty + GES.  The primary outcomes were clinical success, defined as an improvement in patient symptoms based on established assessment systems, and improvement in gastric emptying studies (GES). A Bayesian network meta-analysis was performed using a combined effects model to integrate direct and indirect comparisons, based on the surface under the cumulative order curve (SUCRA), to determine the relative ranking of each treatment's efficacy.

49 studies comprising 2722 patients were included in the study. For clinical success, 12 studies (k=12) across 6 treatments (n=6) and 6 unique study designs (d=6) contributed 12 pairwise comparisons (m=12). Compared to placebo, GPOEM showed the highest odds of clinical success (OR 5.72, 95% CI 2.02–16.18, p=0.0010; SUCRA=0.85), followed closely by GPOEM + GES (OR 5.42, 95% CI 1.47–19.99, p=0.0111; SUCRA=0.79) and pyloroplasty (OR 4.64, 95% CI 1.46–14.75, p=0.0093; SUCRA=0.71). BTI and GNS did not demonstrate a statistically significant benefit. For GES improvement, 8 studies (k=8) evaluated 7 treatments (n=7) with 6 designs (d=6), contributing 8 pairwise comparisons (m=8). In comparisons against sham procedures for gastric emptying improvement, pyloroplasty + GES ranked the highest (OR 100.0, 95% CI, 5.79–1728.15; p=0.0015; SUCRA=0.97), followed by GPOEM (OR 13.33, 95% CI 2.82–63.11, p=0.0011; SUCRA=0.69), and GPOEM+GES (OR 11.93, 95% CI 1.47–96.76, p=0.0203; SUCRA=0.63). BTI and GES remained the lowest-performing interventions across both primary outcomes.

Among procedural options for refractory gastroparesis, G-POEM—either alone or in combination with GES—demonstrates the strongest overall efficacy for symptomatic relief and gastric emptying improvement. Pyloroplasty-based therapies also exhibit effective outcomes, especially when paired with GES. This demonstrates its effectiveness in enhancing infectious movement. In contrast, BTI and standalone GES provide limited clinical value.These findings support the prioritization of G-POEM and pyloroplasty as first-line procedural strategies for patients unresponsive to medical management. Future research should aim to standardize outcome measures and explore patient-specific predictors of procedural response, thereby increasing the chances of improving individualized treatment.