Mid-gastric peroral endoscopic myotomy in the treatment of post-sleeve gastrectomy gastric tube twist: Four cases

Abstract

Background and study aims Laparoscopic sleeve gastrectomy (LSG) may lead to symptomatic mid-gastric twist in 0.1% to 4% of cases. Endoscopic balloon dilatation often fails, requiring a switch to Roux-en-Y bypass. Submucosal endoscopic treatment is expanding, so we propose a new technique of fibrosis incision after tunnelization, called medio-gastric peroral endoscopic myotomy (MG-POEM).

Patients and methods Four patients aged 41 to 70 years underwent MG-POEM in 2020 for symptomatic post-LSG medio-gastric twist. The aim was to describe the technique, and document the efficacy, using the Gastric Outlet Obstruction Scoring System (GOOSS) score and a quality-of-life scale (QOLS). The procedures consisted of a POEM with myotomy and fibrosis incision.

Results Median preoperative GOOSS and QOLS were 1/3 ([0–3] and 1.75/10 [0–10], respectively. All procedures were technically successful. One patient had immediate postoperative complications, which were treated conservatively. The median follow-up was 18 months. All patients had improved quality of life and food intake, with median postoperative GOOSS and QOLS of 3/3 and 6,5/10 [6–8], respectively. Two patients required additional pneumatic dilatation for scarring strictures. Follow-up endoscopies and esophagograms showed that the twist had disappeared.

Conclusions MG-POEM shows promise for safe and effective management of post-LSG mid-gastric twist, despite requiring a high level of endoscopic skill to perform submucosal tunneling.

Keywords

POEM - GI surgery - Benign strictures

Publication History

Received: 03 May 2023

Accepted after revision: 08 November 2023

Article published online:
30 January 2024

• References

• 1 Brethauer SA, Hammel JP, Schauer PR. Systematic review of sleeve gastrectomy as staging and primary bariatric procedure. Surg Obes Relat Dis 2009; 5: 469-475 DOI: 10.1016/j.soard.2009.05.011. (PMID: 19632646)
• 2 Rebibo L, Hakim S, Dhahri A. et al. Gastric stenosis after laparoscopic sleeve gastrectomy: diagnosis and management. Obes Surg 2016; 26: 995-1001 DOI: 10.1007/s11695-015-1883-4. (PMID: 26363902)
• 3 Parikh A, Alley JB, Peterson RM. et al. Management options for symptomatic stenosis after laparoscopic vertical sleeve gastrectomy in the morbidly obese. Surg Endosc 2012; 26: 738-746 DOI: 10.1007/s00464-011-1945-1. (PMID: 22044967)
• 4 Burgos AM, Csendes A, Braghetto I. Gastric stenosis after laparoscopic sleeve gastrectomy in morbidly obese patients. Obes Surg 2013; 1481-1486 DOI: 10.1007/s11695-013-0963-6. (PMID: 23604695)
• 5 Al Sabah S, Al Haddad E. Endoscopic management of post-laparoscopic sleeve gastrectomy stenosis. Surg Endosc 2017; 3559-3563 DOI: 10.1007/s00464-016-5385-9. (PMID: 28032219)
• 6 Deslauriers V, Beauchamp A, Garofalo F. et al. Endoscopic management of post-laparoscopic sleeve gastrectomy stenosis. Surg Endosc 2018; 32: 601-609
• 7 Fayad L, Simsek C, Oleas R. et al. Safety and efficacity of endoscopically secured fully covered self-expandable metallic stents (FCSEMS) for post-bariatric complex stenosis. Obes Surg 2019; 29: 3484-3492
• 8 Donatell G, Dumont JL, Pourcher G. et al. Pneumatic dilatation for functional helix stenosis after sleeve gastrectomy: long term follow up (with videos). Surg Obes Relat Dis 2017; 13: 943-950
• 9 Shnell M, Fishman S, Eldar S. et al. Balloon dilatation for symptomatic gastric sleeve stricture. Gastrointest Endosc 2014; 79: 521-524
• 10 Lorenzo D, Gkolfakis P, Lemmers A. et al. Endoscopic dilation of post-sleeve gastrectomy stenosis: long-term efficacy and safety results. Obes Surg 2021; 31: 2188-2196
• 11 Ogra R, Kini GP. Evolving endoscopic management options for symptomatic stenosis post laparoscopic sleeve gastrectomy for morbid obesity: Experience at a large bariatric surgery unit in New Zealand. Obes Surg 2015; 25: 242-248
• 12 Agnihotri A, Barola S, Hill C. et al. An algorithmic approach to the management of gastric stenosis following laparoscopic sleeve gastrectomy. Obes Surg 2017; 27: 2628-2636 DOI: 10.1007/s11695-017-2689-3. (PMID: 28470488)
• 13 Costa MN, Capela T, Seves I. et al. Endoscopic treatment of early gastric obstruction after sleeve gastrectomy: report of two cases. GE Port J Gastroenterol 2015; 23: 46-49 DOI: 10.1016/j.jpge.2015.07.008. (PMID: 28868430)
• 14 Lazzati A, Bechet S, Jouma S. et al. Revision surgery after sleeve gastrectomy: a nationwide study with 10 years of follow-up. Surg Obes Relat Dis 2020; 16: 1497-1504
• 15 Acquafresca PA, Palermo M, Rogula T. et al. Early surgical complications after gastric by-pass: a literature review. Arq Bras Cir Dig 2015; 28: 74-80 DOI: 10.1590/S0102-67202015000100019. (PMID: 25861076)
• 16 Schlottmann F, Luckett DJ, Fine J. et al. Laparoscopic Heller myotomy versus peroral endoscopic myotomy (POEM) for achalasia: A systematic review and meta-analysis. Ann Surg 2018; 267: 451-460 DOI: 10.1097/SLA.0000000000002311. (PMID: 28549006)
• 17 Mohan BP, Chandan S, Jha LK. et al. Clinical efficacy of gastric per-oral endoscopic myotomy (G-POEM) in the treatment of refractory gastroparesis and predictors of outcomes: a systematic review and meta-analysis using surgical pyloroplasty as a comparator group. Surg Endosc 2020; 34: 3352-3367 DOI: 10.1007/s00464-019-07135-9. (PMID: 31583465)
• 18 Farha J, Fayad L, Kadhim A. et al. Gastric per-oral endoscopic myotomy (G-POEM) for the treatment of gastric stenosis post-laparoscopic sleeve gastrectomy (LSG). Obes Surg 2019; 29: 2350-2354 DOI: 10.1007/s11695-019-03893-6. (PMID: 31001761)
• 19 Zhang LY, Canto MI, Schweitzer MA. et al. Gastric per-oral endoscopic myotomy (G-POEM) for the treatment of gastric sleeve stenosis: a feasibility and safety study. Endoscopy 2022; 54: 376-381 DOI: 10.1055/a-1544-4923. (PMID: 34225370)
• 20 De Moura EGH, de Moura DTH, Sakai CM. et al. Endoscopic tunneled stricturotomy with full-thickness dissection in the management of a sleeve gastrectomy stenosis. Obes Surg 2019; 29: 2711-2712 DOI: 10.1007/s11695-019-03919-z. (PMID: 31140166)