Per-Oral Endoscopic Myotomy: The Preferred Method of Myotomy in the Morbidly Obese

Angela Laface, MD, David Bromberg, MD, Steven B Clayton, MD, Joel Richter, MD, Vic Velanovich, MD. University of South Florida

Introduction: Achalasia, which was previously a disease of patients of low or normal weight, is now being diagnosed in patients who are morbidly obese. This poses challenges in surgical treatment as visualization of the esophageal hiatus can be compromised in such patients and the risk of postoperative hiatal hernia is greater. In addition, morbidly obese patients would be candidate for bariatric surgery and prior hiatal surgery may be compromised by a laparoscopic Heller myotomy with or without a Dor fundoplication. Per-oral endoscopic myotomy (POEM) may offer an alternative to Heller myotomy avoid these issues. We report two morbidly obese achalasia patients who were treated with POEM to illustrate these points.

Case 1. A 46 year old male who initially weighed over 500 lbs. developed dysphagia. This was both to solids and liquids. He lost over 60 lbs. because of this and it greatly interfered with his professional activities. His body mass index (BMI) was 64 kg/m2. He was also considered bariatric surgery. He was evaluated and found to have type 2 achalasia. His pretreatment achalasia symptom score (best score 10, worst score 31), was 19.

He underwent POEM without complications. He was discharged to home the next day. On follow-up, he reported complete resolution of his dysphagia symptoms. His postoperative symptom score was 13. Several months later, he went on to a laparoscopic gastric bypass.

Case 2. A 60 year old male with multiple medical problems including coronary artery disease status post coronary stenting and multiple sclerosis, leading to being wheelchair bound, developed dysphagia to solids and liquids. His BMI was 45 kg/m2. He underwent an evaluation and was found to have type I achalasia. His pretreatment achalasia symptoms score was 27.

He underwent a POEM procedure without complications. He was discharge to home the next day. On follow-up, he reported great improvement in his symptoms. His postoperative symptoms score was 13.

Discussion: These cases illustrate the advantages of POEM over laparoscopic Heller myotomy in the morbidly obese patient. Not only is operating in a difficult to visualized field avoided, so it leaving an unaltered field for subsequent bariatric surgery an advantage. In addition, as pneumoperitoneum is avoided, there is less cardiovascular stress in patient with cardiac disease. POEM should be consider the preferred method of myotomy in the morbidly obese

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