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Peroral endoscopic myotomy with simultaneous submucosal and muscle dissection in spastic esophageal disorder
Peroral endoscopy myotomy (POEM) is widely known as a treatment modality for achalasia and its use has been expanding to other spastic esophageal motility disorders  . POEM with simultaneous submucosal and muscle dissection (POEM-SSMD) has been described for achalasia with severe adhesions in the submucosa of the cardia . We present a challenging case, in which tunneling within the submucosa alone before the myotomy was not possible owing to spastic contractions in the mid-esophagus.
A 46-year-old woman presented with a long history of dysphagia, with worsening symptoms and chest pain since the previous year. Esophagogastroduodenoscopy with a standard endoscope showed narrowing at the level of the tracheal bifurcation and it was impossible for the scope to traverse the narrowing ([Fig. 1 a]). An endoscopic ultrasonography (EUS) examination showed a thick band of muscle ([Fig. 1 b]). It was possible to pass a nasal endoscope beyond the level of the narrowing and this revealed several diverticula in the esophagus, along with strong contractions. An esophagram showed abnormal esophageal contractions throughout, with a narrowed lumen ([Fig. 2 a]). High resolution manometry was inconclusive because of the difficulty in placement of the catheter.
The patient was diagnosed with spastic esophageal disorder and underwent POEM ([Video 1]). The mucosal entry was created with a 2-cm longitudinal incision at the 5-o’clock position using a FlushKnife BT (Fujifilm) after submucosal injection. Submucosal dissection was performed to create the submucosal tunnel. As we approached the tight junction with a narrowed tunnel, proceeding with submucosal tunneling alone was not possible. Instead, simultaneous submucosal and muscle dissection had to be performed, which eventually opened up the tunnel ([Fig. 3]). Submucosal tunneling was continued until two penetrating vessels were seen, indicating the distal end of the POEM  , and the endoscopic myotomy was completed once the penetrating vessels were reached. A standard endoscope was then passed smoothly through into the stomach. The mucosal entry site was closed with endoclips.
Video 1 Peroral endoscopic myotomy with simultaneous submucosal and muscle dissection (POEM-SSMD) in a tunnel that was narrowed by spastic esophageal contractions.
An esophagram on day 1 after the procedure showed an improvement in contrast emptying ([Fig. 2 b]). The patient reported significant improvement in her symptoms 3 months later.
Adopting a method of simultaneous submucosal and muscle dissection in a tunnel narrowed because of spastic contractions is feasible to allow successful completion of POEM.
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19 May 2020 (online)
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