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Castro et al. Mini-invasive Surg 2020;4:47 I http://dx.doi.org/10.20517/2574-1225.2020.14 Page 9 of 13

Figure 3. Endoscopic view of the pylorus. Endoscopic view of the transition between the pyloric muscle and the submucosal plain
depicted by the arrow

[54]
treated with POEM. Bashir et al. described 6 patients with achalasia and surgical history of RYGB who
underwent POEM; all but one patient had improvement of symptoms. While this procedure requires
advanced endoscopic skills and more studies in obese patients are required, it shows to be a promising
alternative for the management of achalasia in post-bariatric patients as it avoids manipulation of an
already explored hiatus, providing greater benefit for the patient.

Gastroparesis in bariatrics
Gastroparesis is characterized by a delay in gastric emptying without a mechanical obstruction
that includes a multifactorial etiology. Previously therapies used include botulinum toxin injection,
[61]
endoscopic transpyloric stent placement and fixation, and laparoscopic pyloroplasty . Endoscopic
per-oral pyloromyotomy (POP), also known as gastric per-oral endoscopic myotomy (G-POEM), was
recently introduced as an alternative therapy for pyloric dysfunction. A mucosal lift is performed along
the lesser curve of the stomach with a regular gastroscope. With an endoscopic knife, a transverse
mucostomy is made after which, a submucosal tunnel is developed using the same instrument. The
pylorus is then identified and divided completely [Figure 3]. Once finished, the mucostomy is closed with
[62]
several endoscopic clips . It is worth mention that this procedure is more technically demanding and
[63]
requires advanced endoscopic skills to perform. Rodriguez et al. assessed 100 patients with refractory
2
gastroparesis that were treated with POP. Preoperatively, the mean BMI was 25.3 kg/m . Of those, 21%
2
of the patients had a BMI > 30 kg/m . There was improvement of the Gastroparesis Cardinal Symptom
Index (GCSI) score on all types of gastroparesis. Complications occurred in 10% of the patients including
[64]
gastrointestinal bleeding, dehydration, capnoperitoneum, and subcutaneous emphysema. Farha et al.
reported a case of a 43-year-old female with a history of LSG who presented with upper gastrointestinal
obstructive symptoms that worsened progressively. After not responding to medical therapy or endoscopic
pneumatic balloon dilation, the physicians decided to perform endoscopic per-oral pyloromyotomy.
The patient was successfully treated without complications. In our experience, post-sleeve patients with
gastroparesis have been safely and effectively managed with POP. Nonetheless, there is insufficient evidence
in obese patients and further studies are needed.