Download PDF
CC BY 4.0 · Endoscopy 2024; 56(S 01): E858-E859
DOI: 10.1055/a-2420-7769
E-Videos

Standard peroral endoscopic myotomy combined with open peroral endoscopic myotomy for refractory sigmoid-type achalasia

Fu Guan  ‡
1   Gastroenterology, Meizhou Peopleʼs Hospital, Meizhou, China (Ringgold ID: RIN608523)
,
Boying Liu‡
1   Gastroenterology, Meizhou Peopleʼs Hospital, Meizhou, China (Ringgold ID: RIN608523)
,
Qunji Zhang
2   Center of Scientific Research and Experiment, Meizhou Peopleʼs Hospital, Meizhou, China (Ringgold ID: RIN608523)
,
Shengbing Wang 
1   Gastroenterology, Meizhou Peopleʼs Hospital, Meizhou, China (Ringgold ID: RIN608523)
› Author Affiliations
› Further Information
Also available at
  Permissions and Reprints

Peroral endoscopic myotomy (POEM) is a feasible, safe, and effective endoscopic treatment for achalasia [1] [2] [3]. However, standard POEM has limitations when managing sigmoid-type achalasia due to the complexity of anatomical structure in this type of achalasia [4]. We report a case of refractory sigmoid-type achalasia that was successfully treated with a combination of standard POEM and open POEM.

A 66-year-old woman with a 20-year history of recurrent dysphagia was admitted to our hospital. Meglumine diatrizoate esophagram and gastroscopy revealed sigmoid-type achalasia ([Fig. 1]), and she was subsequently diagnosed with type III achalasia. Standard POEM was initially performed under general anesthesia with endotracheal intubation. A submucosal incision was made 12 cm above the esophagogastric junction (EGJ), and a submucosal tunnel was created through a longitudinal incision of the mucosal and submucosal layers of the posterior wall ([Fig. 2] a). However, the mucosal surface of the tunnel ruptured, and the waterjet nozzle became blocked when the tunnel extended to the S-shaped esophageal bend, located 4 cm from the EGJ, making it impossible to continue ([Fig. 2] b). As a result, we terminated the standard POEM prematurely and proceeded with open POEM ([Video 1]). This involved a full-thickness incision of the esophageal muscular layer, extending from 7 cm to 3 cm above the EGJ through the tunnel ([Fig. 2] c, d). The mucosal, submucosal, and muscular layers were dissected longitudinally from 3 cm above to 2.5 cm below the EGJ, along the posterior wall of the lower S-shaped esophagus ([Fig. 2] e, f). Finally, titanium clips were used to close the mucosal rupture and the tunnel entrance ([Video 1]). The patient was discharged 5 days after surgery and followed up for 1 year without recurrence ([Fig. 3]).

Zoom Image
Fig. 1 Appearance of sigmoid-type achalasia. a Esophagram showing sigmoid-type changes in the lower esophagus. b Endoscopic view of food and fluid retention in the esophageal lumen.
Zoom Image
Fig. 2 Endoscopic treatment of sigmoid-type achalasia. a A submucosal tunnel was established. b The mucosal surface of the tunnel ruptured. c, d Full-thickness incision of the esophageal muscular layer was made in the tunnel (c) and extended (d). e, f Esophageal mucosal (e), submucosal, and muscular layers (f) were dissected longitudinally in the S-shaped lower esophagus.
Zoom Image
Fig. 3 Preoperative and postoperative esophagrams. a Preoperative esophagram is shown. Standard peroral endoscopic myotomy (POEM) was performed at one end of the S-shaped esophagus (red arrow) and open POEM was performed at the other end (blue arrow). b, c Esophagrams performed at 3 days (b) and 1 month (c) postoperatively.
Standard peroral endoscopic myotomy (POEM) combined with open POEM for refractory sigmoid-type achalasia in a 66-year-old woman with a 20-year history of recurrent dysphagia.Video 1

Endoscopy_UCTN_Code_CPL_1AH_2AZ_3AZ

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

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/).

This section has its own submission website at https://mc.manuscriptcentral.com/e-videos.



Publication History

Article published online:
14 October 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/).

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Hasan A, Low EE, Fehmi SA. et al. Evolution and evidence-based adaptations in techniques for peroral endoscopic myotomy for achalasia. Gastrointest Endosc 2022; 96: 189-196
    CrossrefPubMedSearch in Google Scholar
  • 2 Kuipers T, Ponds FA, Fockens P. et al. Peroral endoscopic myotomy versus pneumatic dilation in treatment-naive patients with achalasia: 5-year follow-up of a randomised controlled trial. Lancet Gastroenterol Hepatol 2022; 7: 1103-1111
    CrossrefPubMedSearch in Google Scholar
  • 3 Saleh CMG, Familiari P, Bastiaansen BAJ. et al. The efficacy of peroral endoscopic myotomy vs pneumatic dilation as treatment for patients with achalasia suffering from persistent or recurrent symptoms after laparoscopic heller myotomy: a randomized clinical trial. Gastroenterology 2023; 164: 1108-1118.e3
    CrossrefPubMedSearch in Google Scholar
  • 4 Pan Z, Gao Z, Sun Z. et al. Retrograde navigational tunnel technique in peroral endoscopic myotomy for sigmoid-type achalasia. Endoscopy 2024; 56: E344-E345
    Thieme ConnectPubMedSearch in Google Scholar