Achalasia following bariatric surgery presents a rare and complex challenge, demanding specialized approaches to diagnosis and treatment. This article explores the connection between bariatric surgery and the subsequent onset of achalasia, with a focus on peroral endoscopic myotomy (POEM) as a treatment option.
Introduction to Achalasia and Bariatric Surgery
Achalasia is a rare chronic disorder that affects the esophageal smooth muscle, impairing the relaxation of the lower esophageal sphincter (LES) and disrupting normal esophageal contractions. The primary cause involves the loss of inhibitory nerve function, potentially triggered by an autoimmune attack on the esophageal myenteric nerves.
Bariatric surgery, including Roux-en-Y gastric bypass (RYGB) and laparoscopic sleeve gastrectomy (LSG), is increasingly performed to combat morbid obesity. However, some patients who undergo these procedures may develop achalasia, possibly due to mechanical effects of gastric banding, neurological damage during surgery, or endocrinological alterations affecting gastric secretions.
Traditional and Emerging Therapies for Achalasia
Traditional treatments for achalasia include pneumatic dilation, botulinum toxin injections, and laparoscopic Heller myotomy (LHM). POEM has emerged as a safe and effective alternative, particularly for patients with prior endoscopic or surgical interventions. Studies have shown that POEM's efficacy is comparable to LHM, with a notable safety profile. Higher post-operative reflux rates, however, appear to be associated with POEM compared to LHM.
POEM has been proposed as a first-line option for patients with previous abdominal surgery or obesity. While most data focus on treatment-naïve patients, POEM has been successfully performed in patients with previous LHM, confirming its feasibility even in a surgically altered gastroesophageal junction (GEJ). Concerns have been raised about the technical feasibility of POEM in post-bariatric patients due to surgical sutures in the dissection plane and adherence formation near the GEJ.
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Aims and Methods of the Study
This article aims to explore the hypothetical connection between bariatric surgery and the subsequent onset of achalasia. To address the need for further knowledge about the efficacy and safety of POEM after bariatric surgery, a review of the available literature on the subject was conducted.
A literature review was performed to identify studies reporting on POEM after bariatric procedures. The search was conducted on PUBMED/Medline, EMBASE, and Scopus databases using a combination of medical terms: “achalasia”, “POEM”, “endoscopic myotomy”, “bariatric”, “sleeve” and “gastric bypass”. All studies published from inception to July 2023 were screened by title and abstracts and considered for eligibility. References of review articles were also hand-searched. Eligibility criteria included endoscopic treatment of achalasia after bariatric surgery and reporting on outcomes of technical and clinical success after POEM. Exclusion criteria were POEM performed for non-achalasia motility disorder, co-performance of POEM and bariatric procedure, surgical treatment, and review or editorial articles. Data regarding demographic, clinical, and procedural variables (sex, age, bariatric intervention, time of achalasia development after surgery, manometric subtype) were extracted from all studies included and reported in a standardized Excel database. Endpoints of interest were technical success, clinical success, adverse events, postprocedural reflux, and PPI use. Statistical analysis was limited to descriptive analysis (frequencies and percentages; mean, median, standard deviations, and ranges). Additionally, a case of a successful POEM performed in our Institute on a female patient diagnosed with achalasia 2 years after LSG is presented.
Case Presentation: POEM After Laparoscopic Sleeve Gastrectomy (LSG)
A 42-year-old woman was referred to a gastroenterology clinic for dysphagia, regurgitation, chest pain, and weight loss of 10 kg, with an Eckardt score of 9. She had undergone LSG 26 months earlier, and symptoms started nearly 1 year after surgery, with dysphagia worsening after a successful childbirth. A timed barium esophageal X-ray showed a dilated esophagus with esophageal contrast stasis. No issues related to the previous bariatric surgery were found. The upper endoscopy confirmed esophageal dilation with food stasis, while the gastric sleeve was regular. High-resolution manometry confirmed a type II achalasia with an LES-integrated relaxation pressure (IRP) of 39.3 mmHg.
POEM was planned and performed according to our protocol. Technical success was achieved, and anterior myotomy was performed without issues, although distal tunneling inside the gastric side was technically difficult because of increased submucosal fibrosis, likely related to postsurgical alterations. No adverse procedural events occurred. The post-operative course was uneventful, a soft oral diet was started after 24 h, and the patient was discharged the day after the procedure. At her first follow-up visit after three months from the procedure, the patient underwent upper gastrointestinal endoscopy and pH-metry, which showed grade A esophagitis with a normal acid exposure time: 0.8% (Demeester Score: 2). The high-resolution manometry showed a normal LES-IRP after POEM (7.4 mmHg). The patient reported a complete resolution of dysphagia and chest pain (Eckardt score of 0) with a weight regain of 4 kg and only complained of mild reflux symptoms, which were controlled with mild proton-pump inhibitor therapy (omeprazole 20 mg). Barium esophageal X-ray showing marked esophageal dilation and contrast stasis suggestive of achalasia. POEM: Myotomy phase of the procedure.
Literature Review Results
The literature research yielded a total of nine articles, including a total of 40 patients who developed achalasia after bariatric surgery. One article was excluded because follow-up data were not reported. Eight articles were included in the final analysis. The studies were published between 2014 and 2023. Seven studies were performed in the United States, with only one European report; four studies were single-patient case reports. Six studies were single-center-based, two were multi-centric; all studies had a retrospective design. Studies and patient characteristics are summarized in Table 1. Study characteristics. Luo et al. Sanaei et al. Bashir et al. Crafts et al. Kolb et al. Donatelli et al. Bomman et al. Two studies (Bashir et al. [20] and Craft et al. [21]) included patients with post-bariatric-surgery achalasia treated with different procedures. In these cases, only POEM cases were evaluated in these series [20,21]. Moreover, Bashir et al. included a total of six patients with achalasia prior to and following RYGB, but two of these had achalasia prior to RYGB and were not evaluated in our review [20]. In the Craft et al. series, 9 of 13 patients were diagnosed with achalasia after bariatric surgery and of these, only one was treated with POEM [21]. The eight articles included the reported outcomes of 40 patients treated with POEM for achalasia after bariatric surgery (34 RYGB, 6 LSG) [15,17,18,20,21,22,23]. In the case reported by Donatelli et al., POEM was performed in a female patient with prior multiple bariatric surgical procedures: a laparoscopic lap band, followed by LSG and, finally, by RYGB [22]. In the total population, 9/39 (23%) were men (one study did not specify the sex of the patient included); the mean age was 54.8 years (±8.85 years). The mean time from bariatric surgery to POEM was 8.86 ± 2.66 years (reported in eight studies). The mean follow-up time was 35.5 ± 27.5 months. According to the current Chicago classification, 12 patients (30%) had type I, 19 patients (47.5%) had type II and 9 patients (22.5%) had type III manometric sub-type of achalasia. The pre-POEM mean IRP was 25.4 ± 1.2 mm Hg (four studies did not specify the value), whereas the post-POEM IRP value was missing in all the studies reported. The pre-POEM mean Eckardt score was 6.91 ± 1.79 and the post-POEM Eckardt score was 1.6 ± 1.4 (two studies did not specify the data). Twenty patients (50%) had undergone previous therapies for achalasia, namely, three (7.5%) had undergone a prior Heller myotomy, nine (22.5%) had undergone a botulinum toxin injection and nine (22.5%) patients had undergone pneumatic dilation (in the Kolb et al. series, one patient had undergone both botulinum toxin injection and Heller myotomy). Overall, there were 20 (50%) naïve patients, with no previous treatment for achalasia. Technical success was achieved in 39 cases (97.5%), and the only technical failure was reported in the study by Bomman et al. [23], where one patient had an esophageal leak that was managed endoscopically. Clinical success was reported in 34 patients (85%). Recurrence of symptoms was reported in one patient with type III achalasia in the series by Bashir et al. [20]; the only patient evaluated in the study by Crafts et al. [21] underwent pneumatic dilatation after POEM, and should therefore be considered a clinical failure of POEM; in the study by Kolb et al. [15], out of six patients, the authors reported that one had recurrent candida esophagitis, whereas another had relapsing achalasia symptoms. Despite Bomman et al. [23] declaring a clinical success rate of 93.8% [15,16], with one patient undergoing pneumatic dilation after POEM, symptoms recurred in two patients (3 months and 12 months after POEM), and they were both considered a clinical failure in our analysis. In all the studies, there were no severe adverse events reported, with the only one being one esophageal leak [23], which also resulted in a technical failure. A postprocedural symptomatic evaluation was lacking in almost all of the studies included in this review. The study by Kolb et al. specified that two out of the three patients with prior LSG had LA grade A/B reflux esophagitis, while in the third patient, candida esophagitis was described. In the study by Bomman et al., 5/16 patients complained of reflux symptoms after POEM [15]. None of the included studies reported if patients were placed on PPI therapy after POEM.
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The Rising Incidence of Obesity and Esophageal Motor Disorders
The incidence of obesity in the general population is increasing, with recent estimates suggesting that nearly 40% of the adult population in the US may be affected. Consequently, the number of patients with morbid obesity undergoing bariatric surgery is expected to rise. Esophageal motor disorders, including achalasia, are also showing an increasing trend. Recent epidemiological studies indicate that the prevalence of achalasia may be around 3 per 10,000, with an incidence near 3 per 100,000 per year. This increase may be related to the widespread use of high-resolution manometry, improved case collection, or an actual increase in incidence.
Obese patients may have a higher incidence of esophageal motor disorders. Factors contributing to this include increased abdominal pressure obstructing bolus progression, a higher incidence of gastroesophageal reflux, and hormonal factors like leptins. Leptin, derived from adipose tissue, can alter gastric and intestinal motility.
POEM: A Minimally Invasive Approach to Treating Achalasia
POEM is a minimally invasive, endoscopic procedure used to treat achalasia. During POEM, a doctor inserts an endoscope into the patient’s mouth and guides it down into the esophagus. The doctor uses instruments passed through the scope to make a small cut in the mucosa, the membrane that lines the esophagus. An electric scalpel at the tip of a small flexible catheter, also called an electrocautery knife, uses electric current to cut through tissue and also seal blood vessels. The doctor inserts the endoscope into this small incision, and can pass the endoscope via a temporary tunnel through a middle layer of esophageal tissue called the submucosa. He or she guides the endoscope through this tunnel until it reaches the lower esophagus. Once there, the doctor makes incisions in the LES, as well as in the muscle in the lower esophagus and upper stomach, so that it relaxes and allows food to pass into the stomach. The doctor may check the adequacy of the myotomy by using a special pressure balloon (called an Endoflip) during the procedure. The doctor then withdraws the endoscope, inspecting the tunnel along the way to check for signs of tears and bleeding, then closes the initial incision with small clips or sutures passed through the scope.
POEM vs. Traditional Heller Myotomy
Traditionally, achalasia is treated with a Heller Myotomy - a one-time procedure in which the muscles of the esophagus and the esophageal sphincter are cut, releasing tension and allowing patients to swallow normally. The Peroral Endoscopic Myotomy takes the Heller procedure and improves upon it. By using an endoscope, the surgeon is able to see inside of the esophagus and perform the surgery without needing to make external incisions. This reduces the complication rate while minimizing patient discomfort and pain.
Outcomes of POEM are comparable to the Heller myotomy, which is the gold standard. Heller has equivalent outcomes to balloon dilation. However, dilatation requires repeat interventions, has some anatomical limitations, and risk of perforation.
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Preparing for POEM
A day or two before the procedure, you will be put on a liquid diet. If you are on blood thinners, you must stop using them prior to the procedure. Other medications may need to be adjusted as well.
Post-Procedure Care and Recovery
You typically stay in the hospital overnight after the procedure and may be given medication for pain control. An esophagram-an X-ray of the esophagus-may be performed to check that the esophagus is emptying. To give the esophagus time to heal after POEM, you should follow a liquid diet for a week after the procedure, then progress to a soft food diet for another week before finally introducing other foods.
The morning after the procedure, you will undergo a barium X-ray to ensure that the esophagus muscle is open and that there is no leakage. Follow-up care includes meeting with your surgeon as an outpatient seven to 10 days after you have the procedure done.
For 6 weeks after your surgery, you should avoid any medications that thin your blood, even medications like Aleve (naproxen) or Advil (ibuprofen) to avoid bleeding in your esophagus.
It is important to stay active after surgery, you should walk a few times a day every day while you recover.
Advantages of POEM
- Minimally invasive, performed during an endoscopy rather than through an incision, offering a quicker recovery without stitches.
- Eliminates the need for abdominal incisions.
- POEM is about 90% effective in relieving symptoms in patients.
- Significantly safer than its predecessor, the Heller Myotomy.
Risks Associated with POEM
While POEM is a safe procedure, it does come with certain risks. Fortunately, complications from POEM are rare but may include tears in the tissue lining the esophagus (the mucosa), bleeding, collapsed lung, and pneumomediastinum (air in the mediastinum, the space between the lungs). While the Heller myotomy procedure often includes fundoplication, a procedure to reduce acid reflux into the esophagus, this is not usually part of the POEM procedure. This means that after POEM, stomach acid may more easily flow back up into the esophagus. Because of this, people who undergo POEM may develop gastrointestinal reflux disease (GERD); however, this is typically managed with the use of acid-blocking medications, such as proton pump inhibitors, taken once a day.