S2188 Efficacy and Safety of Esophageal Peroral Endoscopic Myotomy (E-POEM) in Patients With History of Bariatric Surgery: A Multicenter Retrospective Study

Introduction: Achalasia affects up to 7.2% of post Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) patients, often years later and confirmed by manometry. Altered anatomy creates distinct esophageal peroral endoscopic myotomy (E-POEM) challenges: RYGB distorts the gastroesophageal junction (GEJ), requiring tunnel extension into the pouch or Roux limb, while SG yields a narrow, scarred sleeve that can limit distal myotomy. Small series report technical success of 97.5–100% and clinical relief of 67–100% with tailored modifications, myotomy orientation, careful tunneling, and adjusted lengths. However, limited cohorts, follow-up, and inconsistent outcome definitions necessitate larger multicenter studies. Methods: Between 2020 and 2024, we retrospectively reviewed adult achalasia patients with prior RYGB or SG who underwent E-POEM at 6 tertiary U.S. centers. Patient demographics, procedural details, and follow-up outcomes were collected. The primary endpoint was clinical success defined as Eckardt score ≤3 at 6 months. Secondary endpoints included technical success (completion of planned myotomy) and adverse events. Results: A total of 22 patients (mean age: 59.9 ± 10.7 years; 16 woman) with achalasia and a history of bariatric surgery underwent E-POEM with median follow up of 12 months. Thirteen patients (59%) had undergone RYGB, 5 (22.7%) sleeve gastrectomy and one gastric banding. All procedures were technically successful, with posterior myotomy performed in 18 patients. The mean ± SD myotomy length was 10.81 ± 5.91 cm, extending an average of 2.5 cm beyond the GEJ. The mean procedure duration was 50.5 minutes, and the average hospital stay was 1.36 days. Post-procedure complications included chest pain in 2 patients and regurgitation in 2 patients. The post-procedure Eckardt score was available for 19 patients, with clinical success achieved in 17 (89.4%). Conclusion: E-POEM is both feasible and effective in achalasia patients with prior bariatric surgery, supporting its use as first-line therapy in this group. Limitations include retrospective design, small cohorts, and inconsistent outcome measures. Prospective multicenter trials with standardized endpoints are needed.