Comment on: Endoscopic and surgical treatment options for gastroparesis: systematic review and network meta-analysis.

Correspondence to: Martin Storr (email: m.storr@internistenzentrum.de)

Center for Endoscopy

Starnberg

Germany

BJS, https://doi.org/10.1093/bjs/znaf183, published 29 September 2025

We read with great interest the BJS article entitled ´Endoscopic and surgical treatment options for gastroparesis: systematic review and network meta-analysis` by Eckhardt et al1. The study provides significant insights into the endoscopic and surgical treatments for gastroparesis. However, several methodological aspects warrant critical consideration. The paper reports a well-designed network meta-analysis. However, we have some concerns regarding the overall discussion.

First, gastroparesis remains difficult to delineate from functional dyspepsia (FD). Even experts in neurogastroenterology have difficulties, as both disorders share overlapping symptoms and partially convergent pathophysiology.2 Reliance on detection of delayed gastric emptying at a singular time point as the defining diagnostic criterion risks inclusion of FD cases with modest motility impairment, thus introducing biological and symptomatic heterogeneity that may distort comparative efficacy. Thus, the heterogenous studies included in the meta-analysis may rather represent overlapping functional dyspepsia instead of “true” gastroparesis with severe and continuous prolongations in gastric emptying.

Second, despite the named aim to compare the efficacy of dietary advice, pharmacotherapy and interventions, the final restriction of the network to interventional approaches—G-POEM, pyloroplasty, gastric electrical stimulation, and botulinum toxin injection—omits medical and dietary therapies, which constitute the first-line management in most consensus guidelines.3 Consequently, the proposed tiered algorithm suggesting G-Poem being the most effective short-term intervention for gastroparesis lacks a true benchmark against conservative therapy, limiting its clinical applicability. Unfortunately, this results in a conclusion in the abstract that G-POEM and GES are the most effective treatments rather than limiting to most effective interventional treatments.

Third, the pooling of heterogeneous outcome measures and predominance of non-randomized retrospective designs with frequently inadequately controlled participant selection further attenuates confidence in the finally suggested ranking hierarchy of treatment approaches. A future integrated meta-analysis encompassing pharmacological, dietary, and interventional strategies, harmonized by standardized symptom metrics, and a clear focus on controlled trials in ideally patients with severe forms of gastroparesis would more accurately result in a potentially tiered treatment algorithm of this complex disorder.