Keywords
POEM - GI surgery - Benign strictures
Introduction
Obesity is a public health problem and the number of bariatric surgical procedures
is increasing, indicated in patients with a body mass index (BMI) >40 kg/m2 with or without comorbidities, or patients with a BMI between 35 and 40 kg/m2 with complications related to obesity that may improve after surgery. The most frequent
surgical approach is laparoscopic sleeve gastrectomy (LSG) [1].
Along with fistulas, gastric strictures are the most frequent post-LSG complications.
Their incidence varies between 0.1% and 4% [1]
[2] and they induce nausea, vomiting, epigastric pain, reflux and consequently dehydration,
metabolic deficiency, and under-nutrition. The median time of symptom onset varies
between 1 and 61 months depending on the study [2]
[3]
[4]. Among the identified etiologies of post-LSG stenosis is mid-gastric twist with
a volvulus-like mechanism for which management is routinely a failure with endoscopic
management. Endoscopic management includes stenting (with covered metallic stent),
pneumatic balloon dilatation (Rigiflex, Boston Scientific, United States), or hydraulic
dilation requiring iterative sessions every 2 to 4 weeks [5]
[6]
[7]. Surgery is another, more radical option, consisting of conversion toward Roux-en-Y
bypass (RYGB) [8]
[9]
[10].
The success rate of endoscopic approaches varies between 44% and 100% according to
the literature, with mainly short-term benefits and high recurrence rates [11]
[12]
[13]. Thus, the rate of surgical conversion to RYGB after failure of endoscopic treatment
can reach 56% [14]. As for pneumatic dilatation, it is safe but often requires iterative dilatation
sessions every 2 to 4 weeks, and thus, repeated general anesthesia. Few studies also
suggest the potential problem of decreased benefit concerning long-term weight loss
in patients who underwent pneumatic dilatation with 40-mm Rigiflex [5]
[6]. Regarding endoscopic stenting, migration remains a problem with a rate higher than
50%, which may itself induce complications such as bleeding, occlusion, or perforations
[7]. Moreover, the benefit of this technique, evaluated at 100% in the short term, is
not consistent in the long-term period, because symptoms recurrence occurs in more
than 60% of patients after removal [7]
[11]. The overall complication rate for surgical RYGB is between 5% and 10%, limiting
the clinical benefit for its indication as a switch [15].
Recently, submucosal endoscopy has been developed for treating achalasia and gastroparesis.
Per oral endoscopic myotomy (POEM) consists of the creation of a submucosal tunnel
for the realization of a myotomy of the lower esophageal sphincter in achalasia [16]
[17] or pyloric in gastroparesis [18]
[19]. Submucosal management of post-LSG stricture has also been briefly suggested, with
promising results [20]. Thus, we propose our experience of medio-gastric POEM for the management of post-LSG
gastric tube twist.
Patients and methods
This was a single-center series of four consecutive patients aged 40 to 71 years performed
at the Hôpital Nord, Marseille.
Patients
The patients included had all undergone surgical sleeve gastrectomy within the previous
10 years, complicated with mid-gastric twist post-sleeve gastrectomy managed by mid-gastric
POEM (MG-POEM). The gastric tube twist was diagnosed by the realization of an esophagogram
and an upper gastrointestinal endoscopy ([Fig. 1]
a and [Fig. 1]
b). All patients were symptomatic with significant clinical impact on food intake (nausea
+/- vomiting +/- reflux +/- abdominal pain +/ dehydration +/- under-nutrition), and
thus, decreased quality of life (QoL). All the patients had undergone a previous endoscopic
treatment that was a failure. The patients included were not eligible for revision
surgery because of patient or surgeon refusal (surgery too risky or not feasible).
The decision to propose MG-POEM was validated during a Multidisciplinary Obesity Meeting
and after patients signed an informed consent.
Fig. 1
a Preoperative barium radiological study showing the mid-gastric twist b Upper gastrointestinal endoscopy showing the mucosal aspect of the medio-gastric
twist responsible for the symptoms
Endoscopic procedure
The procedure ([Video 1]) was performed under general anesthesia in a supine intubated patient. A large-channel
gastroscope with CO2 insufflation and a fitted-cap was used (Fuji 3.8 mm, Japan), as well as a Triangle
Knife J type dissection knife (Olympus, Japan). The procedure consisted of the following
steps ([Fig. 2]): 1) injection of blue-tinted saline 4 to 5 cm upstream from the twist on the posterior
side of the stomach; 2) mucosal incision to access the submucosal space; 3) creation
of a tunnel extending beyond the twisted area and ending in the antrum; 4) gastric
myotomy of the entire twisted area up to the mucosal opening; and 5) closure of the
mucosal access by through-the-scope clips.
Video showing the different steps of the GPOEM procedure.Video 1
Fig. 2
a Injection of blue-tinted saline 4 to 5 cm upstream from the twist on the posterior
gastric wall. b Mucosal incision to access the submucosal space. c Creation of a tunnel extending beyond the twisted area and ending in the level of
the antrum. d Gastric myotomy and fibrotomy of the entire twisted area up to the mucosal opening.
e Closure of the mucosal access by TTS clips.
Patient follow-up and assessment scores
After the intervention, patients were clinically followed up regularly at 1, 3, and
6 months and then annually (phone or consultations). The assessment included gastric
outlet obstruction scoring system (GOOSS) calculation currently used for the evaluation
of symptoms before and after treatment of mechanical gastric obstructions and a QoL
assessment applying a classical numerical scale (NS) from 0 to 10 (0=very poor QoL,
10=very satisfactory QoL).
Results
Patient characteristics
Four patients aged 41 to 70 years (all female) underwent MG-POEM for the management
of post-LSG twist with a median of 5.5 years [1]
[2]
[3]
[4]
[5]
[6]
[7]
[8]
[9]
[10] after surgery.
The four patients included had been previously managed by endoscopic techniques, which
did not improve their symptoms: one patient had one session, and another one had two
sessions of dilatation with a 15-mm hydraulic balloon; two patients had benefited
from pneumatic dilatation (diameter 30 mm). In two patients, the severe under-nutrition
caused by the presence of the mid-gastric twist required the implementation of long-term
parenteral nutrition (PN); these patients had not been able to be weaned from their
artificial nutrition after the initial endoscopic treatment.
The median preoperative GOSS score was 1/3 (0–3) for all four patients and the median
NS for QoL assessment was 1.75/10 (0–3).
Procedure and complications
MG-POEM was technically successful in all the patients without intraoperative adverse
events in 92 +/- 25 minutes. One patient presented with immediate post-endoscopy complications
with abdominal pain and fever associated with the appearance of a biological inflammatory
syndrome related to a collection in contact with the myotomy area; the evolution was
favorable after the administration of antibiotics for a total of 10 days. The average
hospital stay was 5.25 days (3–10 days).
Efficacy
The median follow-up was 15.5 months [14]
[15]
[16]
[17]. Clinical improvement occurred initially during the first months of follow-up in
all the patients. Two patients experienced recurrence of mild symptoms with some vomiting
and decrease in food intake. Early endoscopic and radiological control showed no more
twist ([Fig. 3]) but a trend toward stenosis induced by a post MG-POEM scar. Pneumatic dilatation
was performed successfully in those two patients (Rigiflex 35 mm) in one and two sessions.
The two patients who had total PN were free of artificial nutrition at 2 months.
Fig. 3 Postoperative barium study showing the deceasing of the mid-gastric twist.
At the end of follow-up, the median GOOSS score was 3 and the mean QoL index was 6.5/10
[6]
[7]
[8]
. The weight of all patients stabilized postoperatively.
All the outcomes and patient information are summarized in [Table 1].
Table 1 Preoperative history, evaluation, and postoperative outcomes in four patients.
|
Patient number
|
Gender/age
|
Background
|
Date of LSG
|
Initial endoscopic treatment of twist post LSG
|
Preop GOOSS (/3)
|
Preop QoL scale (/10)
|
Adverse events
|
Length of post MG-POEM stay (days)
|
Follow-up (months)
|
Endoscopic revision
|
GOSS at last follow-up (/3)
|
QoL scale at last follow-up (/10)
|
|
QoL, quality-of-life; GOOSS, gastric outlet obstruction scoring system; NIDD, non-insulin-dependent
diabetes; HH, hiatal hernia; PN, parenteral nutrition.
|
|
1
|
F 70
|
Gastric banding 2009, NIDD
|
2014
|
1 session of dilatation with a hydraulic balloon (15 mm)
|
0 (PN)
|
2
|
0
|
3
|
17
|
Pneumatic dilatation x 2 for residual stenosis at M2 et M4
|
3
|
6
|
|
2
|
F 41
|
NIDD
|
2015
|
1 session of dilatation with a pneumatic balloon 30 mm
|
1
|
2
|
Collection in contact with the myotomy area (abdominal pain and fever)
Antibiotics
|
10
|
16
|
0
|
3
|
6
|
|
3
|
F 51
|
Gastric banding 2004
|
2019
|
2 sessions of dilatation with a hydraulic balloon (15 mm)
|
0 (PN)
|
0
|
0
|
5
|
15
|
0
|
3
|
6
|
|
4
|
F 41
|
Fibromyalgia, functional colopathy
|
2010
|
1 session of dilatation with a pneumatic balloon 30 mm
|
3
|
3
|
0
|
3
|
14
|
Pneumatic dilatation x 1 of a residual stenosis at M5
|
3
|
8
|
Discussion
Mid-gastric twist post LSG is a rare complication but may lead to refractory digestive
symptoms, including in the long term under-nutrition, sometimes severe, and impairment
of QoL. The most effective solution to date remains conversion to RYGB, which has
no negligible rates of morbidity and mortality, particularly from a nutritional point
of view, with the worsening of vitamin deficiencies in patients who have already lost
weight following their first bariatric surgery.
POEM is an endoscopic technique in full expansion and the variation applied in this
series seems to be an interesting therapeutic alternative for the management of post-LSG
mid-gastric twists. In this short case series, the MG-POEM procedure demonstrated
promising clinical results, although very preliminary. Indeed, the success rate in
terms of dysphagia was good, with weight regain and substantial QoL improvement in
all our patients. The side effects, which required antibiotic therapy and a longer
hospital stay, did not require surgery.
However, the procedure is technically more complex than a regular POEM because of
fibrosis, vascularization, and the twist itself, and requires a high level of skill
in submucosal endoscopy and dissection. Consequently, this technique has to be performed
in an expert center, and its indication validated by a multidisciplinary staff.
Moreover, in our series, in 50% of the patients, additional pneumatic dilatation sessions
were necessary despite the disappearance of the medio-gastric twist post-LSG on the
endoscopic controls. This is explained by the appearance of a scar inducing a post
MG-POEM stenosis, which evolves favorably after one to two additional sessions of
pneumatic dilatation, with good clinical results after more than 1 year of follow-up.
Conclusions
In conclusion, MG-POEM is promising and warrants future study prospectively in a larger
population to establish a clear decision tree for a rare pathology for which the management
is not clearly codified to date.
