Endoscopy 2018; 50(07): E172-E174
DOI: 10.1055/a-0600-9529
E-Videos
© Georg Thieme Verlag KG Stuttgart · New York

Peroral endoscopic myotomy as a versatile approach to treating complex esophageal disorders

Antonella Putignano
1   Department of Gastroenterology and Hepatopancreatology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
,
Marc Barthet
2   Department of Gastroenterology, Hôpital Nord, Aix Marseille Université, Marseille, France
,
Ricardo Rio-Tinto
3   Digestive Diseases Unit, Champalimaud Clinical Centre, Lisbon, Portugal
,
Guido Costamagna
4   Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
,
Hubert Louis
1   Department of Gastroenterology and Hepatopancreatology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
,
Vincent Huberty
1   Department of Gastroenterology and Hepatopancreatology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
,
Arnaud Lemmers
1   Department of Gastroenterology and Hepatopancreatology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
,
Jacques Devière
1   Department of Gastroenterology and Hepatopancreatology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
› Institutsangaben
Weitere Informationen

Publikationsverlauf

Publikationsdatum:
09. Mai 2018 (online)

Since 2008, peroral endoscopic myotomy (POEM) has evolved as a technique for managing esophageal achalasia [1]. POEM has also recently emerged as a potential therapeutic tool in treating other esophageal motility disorders [2] [3], including Jackhammer esophagus and Zenker’s diverticulum [4]. However, for mid or lower esophageal diverticulum, the surgical treatment is still recommended, despite being associated with high morbidity. In this video case we report the application of the POEM technique as a therapeutic approach in a patient affected by Jackhammer esophagus, distal esophageal spasm, and a large distal esophageal diverticulum ([Fig. 1], [Fig. 2 a]).

Zoom Image
Fig. 1 Barium study showing a large distal esophageal diverticulum and multiple tertiary contractions, suggesting the diagnosis of Jackhammer esophagus.
Zoom Image
Fig. 2 High resolution manometry. a Before treatment. Confirmed diagnosis of Jackhammer esophagus and distal esophageal spasm (50 % premature contractions; 60 % high amplitude contractions; distal contractile integral 8051 mmHg.s.cm; lower esophageal sphincter (LES) pressure 11 mmHg; integrated relaxation pressure 4 s: 5 mmHg.s.cm; 4 cm hiatal hernia). b 1 month follow-up after treatment, showing a significant improvement in the esophageal wall muscle and LES contractility (0 % premature contractions; 20 % high amplitude contractions; distal contractile integral 4616 mmHg.s.cm; LES pressure 4 mmHg; integrated relaxation pressure 4 s: 1 mmHg).

The aim of this POEM variation was to create a submucosal tunnel as a single access both to the diverticular septum, to perform septotomy, and to the esophageal wall muscle and lower esophageal sphincter (LES), in order to perform myotomy ([Fig. 3], [Video 1]).

Zoom Image
Fig. 3 Endoscopic images. a Anatomical relation between the septal fibers and the mucosa flaps at the tunnel entrance. b Submucosal tunnel.

Video 1 A modified peroral endoscopic myotomy technique as a therapeutic approach for treating, with a single submucosal tunnel, a complex case combining Jackhammer esophagus, distal esophageal spasm, and a large distal esophageal diverticulum.


Qualität:

Compared with the classical POEM procedure, five phases were defined. After mucosa incision and submucosal tunneling, the myotomy was performed as a hybrid technique. Initially, an anterograde section of the esophageal wall muscle was dissected, starting from the fibers below the diverticular septum, progressing downstream, and ending in the stomach, beyond the LES section. Next, a retrograde septotomy was performed, beginning from the most distal septal fibers and working toward the proximal ones. At the end, the tunnel entry was sealed using hemostatic clips.

This case report shows that POEM is versatile, safe, effective ([Fig. 2 b]), and minimally invasive. Its evaluation as a therapeutic tool in patients having mid or distal esophageal symptomatic diverticulum, whether associated with motility disorders or not, should be encouraged. However, despite the low rate of overall morbidity and mortality reported for conventional POEM [5], it should be carefully customized to each specific case, in order to reduce the risks of potential complications.

Endoscopy_UCTN_Code_TTT_1AO_2AN

Endoscopy E-Videos
https://eref.thieme.de/e-videos

Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques in gastroenterological endoscopy. All papers include a high quality video and all contributions are freely accessible online.
This section has its own submission website at https://mc.manuscriptcentral.com/e-videos

 
  • References

  • 1 Inoue H, Minami H, Kobayashi Y. et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy 2010; 42: 265-271
  • 2 Mu D, Li YY, Zhang MM. et al. POEM for special patient cohorts: a review. J Dig Dis 2017; 18: 265-272
  • 3 Louis H, Covas A, Coppens E. et al. Distal esophageal spasm treated by peroral endoscopic myotomy. Am J Gastroenterol 2012; 107: 1926-1927
  • 4 Li QL, Chen WF, Zhang XC. et al. Submucosal tunneling endoscopic septum division: a novel technique for treating Zenker’s diverticulum. Gastroenterology 2016; 151: 1071-1074
  • 5 Bechara R, Ikeda H, Inoue H. Peroral endoscopic myotomy: an evolving treatment for achalasia. Nat Rev Gastroenterol Hepatol 2015; 12: 410-426