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DOI: 10.1055/a-2308-2823
Peroral endoscopic mediastinal tunneling myotomy for esophageal achalasia: the first case treated in mediastinal tunnel
Peroral endoscopic myotomy (POEM) has been accepted as an effective and safe therapeutic strategy for esophageal achalasia [1]. However, the submucosal tunnel cannot be established in some patients because of severe fibrosis caused by previous treatment [2].
A 68-year-old woman was admitted due to a 30-year history of progressive dysphagia and regurgitation. She was diagnosed with esophageal achalasia and had previously undergone two pneumatic balloon dilations, without significant improvement in symptoms. The esophagram revealed esophageal dilation and a “bird-beak” sign ([Fig. 1]). Endoscopy revealed a massively dilated esophagus and narrow esophagogastric junction (EGJ) ([Fig. 2]). POEM was planned.
Submucosal injections were administered 10 cm above the cardia, but resulted in no significant lift here or in other attempted injection sites. The submucosal adhesion in the esophagus was severe, making it impossible to establish a submucosal tunnel ([Fig. 3]). A full-thickness incision of the esophageal wall was performed from the mucosal layer at 6 cm above the EGJ to create a mediastinal tunnel ([Video 1]). Full-thickness myotomy started 5 cm above the EGJ and extended distally to 2 cm below the cardia in the mediastinal tunnel ([Fig. 4]). The tunnel entrance was closed with six clips after hemostasis. A nasogastric tube was placed for decompression and monitoring.
Qualität:
The patient remained fasting and started a liquid diet after removing the nasogastric tube on postoperative day (POD) 3. She was able to take solid food on POD 5 and was discharged, uneventfully, on POD 7. A month later, endoscopy showed significant relaxation of the cardia ([Fig. 5]).
Peroral endoscopic mediastinal tunneling myotomy (POEMTM) is a novel technique combining POEM and laparoscopic Heller myotomy, using the mediastinum for operating entry. In this video, we report the first application of POEMTM for achalasia with difficult submucosal tunnel, which may indicate a minimally invasive, safe, and effective alternative.
Endoscopy_UCTN_Code_TTT_1AO_2AG
E-Videos is an open access online section of the journal Endoscopy, reporting on interesting cases and new techniques in gastroenterological endoscopy. All papers include a high-quality video and are published with a Creative Commons CC-BY license. Endoscopy E-Videos qualify for HINARI discounts and waivers and eligibility is automatically checked during the submission process. We grant 100% waivers to articles whose corresponding authors are based in Group A countries and 50% waivers to those who are based in Group B countries as classified by Research4Life (see: https://www.research4life.org/access/eligibility/).
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Publikationsverlauf
Artikel online veröffentlicht:
17. Mai 2024
© 2024. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/).
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References
- 1 Ciomperlik H, Dhanani NH, Mohr C. et al. Systematic review of treatment of patients with achalasia: Heller myotomy, pneumatic dilation, and peroral endoscopic myotomy. J Am Coll Surg 2023; 236: 523-532
- 2 Wu QN, Xu XY, Zhang XC. et al. Submucosal fibrosis in achalasia patients is a rare cause of aborted peroral endoscopic myotomy procedures. Endoscopy 2017; 49: 736-744 DOI: 10.1055/s-0043-113440. (PMID: 28658680)