Endoscopic gastric pacing: A minimally invasive approach for slow wave entrainment in rhythmic and dysrhythmic states

Background: Disordered gastric electrical rhythms contribute to debilitating motility disorders and existing therapies remain largely symptomatic without restoring coordinated activity. Electrical pacing has shown promise but currently relies on surgical techniques, limiting clinical adoption. This study evaluated endoscopic mucosal pacing as a minimally invasive alternative for modulating gastric electrical activity. Methods: In pigs (n=11), intraluminal gastric pacing was delivered via a catheter-based mucosal electrode. Feasibility and efficacy were assessed under distinct electrophysiological states induced by propofol (rhythmic) and isoflurane (dysrhythmic) anesthesia. High-resolution serosal mapping quantified spatiotemporal responses. Pacing parameters, including pulse-amplitude (2-8 mA), pulse-width (100-400 ms), and electrode configuration (unipolar vs bipolar), were systematically varied to determine conditions for reliable entrainment. Results: Mucosal pacing successfully entrained gastric electrical activity under both rhythmic and dysrhythmic conditions. Entrainment outcomes were comparable between unipolar and bipolar configurations. Dysrhythmic states required substantially greater pacing input to achieve entrainment (75% success at 25,600 mA²ms (pulse-amplitude: 8mA, pulse-width: 400 ms)) than rhythmic states (86% at 6,400 mA²ms (pulse-amplitude: 4mA, pulse-width: 400 ms)). Overall, entrainment success was significantly greater under propofol than isoflurane (common odds ratio 3.6; P=0.007). Conclusions: Endoscopic mucosal pacing enables minimally invasive modulation of gastric electrical activity, with state-dependent pacing requirements informing personalized bioelectronic therapies and establishing a translational pathway for ingestible treatment platforms.