Peroral endoscopic myotomy after operative interventions on the gastroesophageal junction

Abstract

Introduction: Per oral endoscopic myotomy (POEM) may be a challenge in patients with previous interventions on the esophagealgastric junction. The degree of fibrosis in submucosal space plays a key role in the feasibility and safety of tunnel technique. Aim: To evaluate the safety of per oral endoscopic myotomy in patients previously operated on the esophageal-gastric junction. Material and methods: Between July 2014 and May 2018, 123 patients underwent POEM in the Moscow Clinical Scientific Center, including 46 (37%) patients previously operated on the esophageal-gastric junction. The group of operated patients involved 41 (89%) patients after pneumatic balloon dilation, 3 (6.5%) patients after Heller myotomy, 1 (2%) patient after previous esophagogastroplication, 1 (2%) after POEM. Results: The POEM procedure was successfully completed all patients. The mean operative was comparable in both groups: 106 min (55-195 min) in previously operated patients and 103 min (45-180 min) in naïve patients. F0 degree was detected in 14 (30%) cases, F1 in 29 (63%), maximal fibrosis (F2) in 3 (6.5%) patients who had previously undergone pneumatic balloon dilation. In patients after Heller's myotomy and esophagogastroplication, the degree of fibrosis reached F1, despite the expected more pronounced fibrosis. In the group of primary patients F0, the degree was detected in 27 (35%) observations, F1 - 46 (60%), severe fibrosis (F2) was detected in 4 (5%). There were no intraoperative complications affecting the tactics of surgical intervention in one observation. There were no major bleeding episodes requiring blood transfusion in either group. In one case in the group of previously operated patients, a mucosal defect was detected after the formation of the tunnel. The lesion was clipped. The technical success of the surgical intervention was up to 100%. There were no intraoperative complications. X-ray examination on the 1st day after intervention with a water-soluble contrast showed appropriate evacuation and no leakage. Patients were discharged the 2nd day after surgery. Conclusions: The history of failed previous surgical interventions is not a contraindication to the POEM procedure and does not significantly affect the course of surgical intervention.