Abstract
Background: Per-oral endoscopic myotomy (POEM) has emerged as a safe and effective treatment modality for achalasia. POEM can be performed after prior endoscopic interventions (botox injection, pneumatic dilation and after POEM) as well as after Laparoscopic Heller myotomy (LHM). However, limited data exists on POEM in patients with prior bariatric surgery. We present two cases of POEM performed in patients with achalasia after bariatric surgery. Case Presentation: Case 1: A 54-year-old male with sleeve gastrectomy for obesity 4 years prior, presented with dysphagia for 9 months. Esophagram showed gastroesophageal junction (GEJ) obstruction to passage of a 13 mm barium pill. High-resolution manometry (HRM) showed type 1 achalasia. He underwent LHM and repair of a 5 cm para-esophageal hernia. Dysphagia recurred in 4 weeks, along with regurgitation, chest pain and weight loss (Eckardt score = 9). After a multi-disciplinary evaluation he decided to undergo POEM. A 12 cm posterior submucosal tunnel and a 9 cm myotomy was performed. Significant angulation, tortuosity and scarring was observed near the GEJ. Surgical sutures in the submucosa and muscle were carefully avoided. Follow up esophagram showed no leak and contrast readily emptied into the stomach. Eckardt score significantly improved to 2 at 3 months. Case 2: A 43-year-old female with RY gastric bypass 7 years prior, presented with dysphagia for 6 months, regurgitation with every meal, chest fullness, and 25 lbs weight loss (Eckardt score 10). HRM showed type 2 achalasia. POEM was considered due to surgically altered anatomy making LHM technically more challenging. A 14 cm submucosal tunnel and 10 cm myotomy was performed posteriorly. Patient had significant clinical improvement at 1 month with Eckardt score 2 and esophagram showed unimpeded passage of contrast into the stomach. Discussion: Achalasia in patients with obesity requiring bariatric surgery is rare but with increasing number of bariatric procedures being performed, endoscopists will likely face challenging situations like those reported here. As POEM gains widespread acceptance for management of achalasia, these cases highlight the fact that POEM can be performed in patients with bariatric surgery, though technically challenging due to angulation, tortuosity and scarring, as well as reduced gastric lumen from prior surgery.Figure: Surgical sutures seen during endoscopic myotomy.
Published Version
Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a call