Efficacy and safety of peroral endoscopic myotomy after prior sleeve gastrectomy and gastric bypass surgery

Table 1 Clinical characteristics of patients with a history of bariatric surgery who underwent peroral endoscopic myotomy

Case	Age Sex	Type of bariatric surgery	Pre-POEM Eckardt Score	Achalasia subtype	IRP (normal < 15)	Prior achalasia treatment1	Months from bariatric surgery to POEM
1	54 M	SG	9	1	NA2	Heller myotomy	47
2	68 M	SG	6	2	22.2	Botulinum toxin injection	71
3	53 F	SG	7	1	23.7	Botulinum toxin injection; Heller myotomy3	165
4	43 F	RYGB	10	2	21.2	None	96
5	31 M	RYGB	44	2	28	Botulinum toxin injection	84
6	37 F	RYGB	10	2	36	None	122

¹Standard endoscopic dilation ≤ 20 mm was not considered as a prior achalasia treatment.

²Probe was not able to be passed beyond the esophagogastric junction, however there was complete aperistalsis consistent with achalasia with prior treatment with Heller myotomy.

³Aborted due to adhesions.

⁴Achalasia diagnosis preceded bariatric surgery. In all other cases achalasia was diagnosed after bariatric surgery. Eckardt score comprised of dysphagia (2) and regurgitation (2) without weight loss. M: Male; F: Female; SG: Sleeve gastrectomy; RYGB: Roux-en-Y gastric bypass; ES: Eckardt Score; IRP: Integrated relaxation pressure of the lower esophageal sphincter (mmHg) as measured by high-resolution esophageal manometry. POEM: Peroral endoscopic myotomy; NA: Not available.

Table 2 Procedural data for peroral endoscopic myotomy

POEM Procedural data (n = 6)	Mean (range)
Submucosal Tunnel length, cm	12.3 (11-14)
Myotomy length, cm	9.3 (9-10)
Extension of myotomy into cardia, cm	2.2 (2-3)
Clips, number	5 (3-7)
POEM time, min	79.8 (47-105)

POEM: Peroral endoscopic myotomy.

Table 3 Outcomes of patients with a history of bariatric surgery who underwent peroral endoscopic myotomy

Case	Type of bariatric surgery	Technical success	Clinical success	Post-POEM Eckardt score	Adverse events	Follow up, mo	Endoscopy findings	Medical comorbities
1	SG	Yes	Yes	3	No	37	Grade A esophagitis	HTN, HLD
2	SG	Yes	No	6	Minor1	21	Candida esophagitis; EndoFLIP DI: 10.22	COPD, TIA, OSA, HTN, type 2 diabetes
3	SG	Yes	Yes	2	No	13	Grade B esophagitisEndoFLIP DI: 5.13	None
4	RYGB	Yes	No	10	No	21	NA	Major depressive disorder, chronic migraines
5	RYGB	Yes	Yes	2	No	33	NA	None
6	RYGB	Yes	Yes	2	No	1.5	NA	Hypothyroidism

¹ER visit for chest pain 5 d after procedure with negative workup.

²EndoFLIP: Esophagogastric junction distensibility index, 60 mL: 10.2 mm²/mmHg; dysphagia and clinical failure likely related to candida esophagitis.

³EndoFLIP: Esophagogastric junction distensibility index, 60 mL: 5.1 mm²/mmHg. SG: Sleeve gastrectomy; RYGB: Roux-en-Y gastric bypass; POEM: Peroral endoscopic myotomy; HTN: Hypertension; HLD: Hyperlipidemia; COPD: Chronic obstructive pulmonary disease; TIA: Transient ischemic attack; OSA: Obstructive sleep apnea; NA: Not available.