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Page 8 of 13 Castro et al. Mini-invasive Surg 2020;4:47 I http://dx.doi.org/10.20517/2574-1225.2020.14

5 years after the initial TORe in 331 post-RYGB patients who had weight regain or inadequate weight loss.
[50]
The results showed that TORe is a safe, effective, and durable therapy for weight regain following RYGB .

Restorative Obesity Surgery, Endolumenal (ROSE) is another available option to reduce the size of the
gastric pouch and the anastomosis. The procedure consists of placement of sutures that surround the
anastomosis or in the stomach wall creating plications that allow for stoma reduction. A prospective
multicenter study that included 116 patients, reported that ROSE was successfully performed in 112 patients
[51]
and had an average of %EWL of 18% .

Strictures
Strictures after bariatric surgery represent a technical challenge. The incidence of this complication varies
significantly based on different operations and different technique. Laparoscopic Roux-en-Y gastric bypass
[52]
(LRYGB) has the highest incidence of anastomotic strictures ranging from 3%-27% while the incidence
of stenosis after LSG ranges from 0.2% to 4% . The most common technique to treat this problem is
[53]
endoscopic balloon dilation.

Dilation of gastro-jejunostomy strictures with endoscopic balloons has proven to be highly successful. In a
study that included sixty-one patients, all responded to dilation without need for formal surgical revision
[52]
with a 2.2% incidence of perforation . The technique involves proper identification of the anatomy and
estimation of the narrowing. The diameter of commonly used diagnostic upper endoscopes ranges between
9 and 10 mm. Inability to pass the scope necessitates the use of smaller balloons, typically 6 or 8 mm.
Sequential dilations can be attempted using manometric feedback. Once a maximal diameter is reached,
the balloon is held in place for 1 min. We rarely exceed a diameter of 15 mm after LRYGB at our institution.
Long standing strictures are less likely to resolve with endoscopic dilatation and may require operative
revision.

MANAGEMENT OF CONCOMITANT CONDITIONS IN THE BARIATRIC PATIENT
Like any other patient, multiple gastrointestinal conditions may arise such as achalasia, gastroparesis, and
cholelithiasis; however, their management pose a challenge for the surgeon as the anatomy is altered after
bariatric surgery and reoperative fields increase the risk of complications. New endoscopic have been
described and are currently taking more predominance than the surgical approach.

Achalasia in bariatrics
Obesity impacts esophageal function by altering the lower esophageal sphincter resting pressures and
motility. Achalasia is an uncommon disease that could also present concomitantly after bariatric surgery.
[54]
[55]
Myotomy had been the preferred therapy to treat patients with achalasia . Most recently, Inoue et al.
introduced esophageal myotomy endoscopically instead of open surgery or laparoscopically, the procedure
known as per-oral endoscopy myotomy (POEM). The therapy consists of dissection of the circular muscle
bundle through a previously created submucosal tunnel at the gastroesophageal junction; after completion,
the mucosal entry is closed with hemostatic clips. Symptom control after POEM is comparable to that
seen with laparoscopic Heller myotomy (LHM) [54-56] . If achalasia presents in post-bariatric patients, the
management remains the same as with a normal anatomy patient. However, given that performing LHM
would involve an additional operation and thus, potential increased operative risk, we consider POEM a
better, non-surgical, less invasive alternative in this setting as well as for failed LHM where POEM serves
as a feasible, safe, and minimally invasive technique [57,58] . We believe that POEM should be considered as
[59]
first option for managing patients with achalasia after bariatric surgery. Recently, Sanaei et al. explored
the outcomes of POEM in 10 patients with RYGB anatomy that presented with achalasia. All patients
[60]
were treated successfully, with no complications, and significant symptom improvement. Luo et al. also
reported a case of a 67-year-old female with previous RYGB that developed achalasia and was successfully