Endoscopy 2018; 50(07): E151-E152
DOI: 10.1055/a-0596-7068
E-Videos
© Georg Thieme Verlag KG Stuttgart · New York

Fluoroscopy-guided peroral endoscopic myotomy for sigmoid-type achalasia

In Kyung Yoo
Division of Gastroenterology, Department of Internal Medicine, Cha Bundang Medical Center, Seongnam-si, Korea
,
Joo Young Cho
Division of Gastroenterology, Department of Internal Medicine, Cha Bundang Medical Center, Seongnam-si, Korea
,
Sang Ah Choi
Division of Gastroenterology, Department of Internal Medicine, Cha Bundang Medical Center, Seongnam-si, Korea
,
Won Hee Kim
Division of Gastroenterology, Department of Internal Medicine, Cha Bundang Medical Center, Seongnam-si, Korea
,
Ki Baik Hahm
Division of Gastroenterology, Department of Internal Medicine, Cha Bundang Medical Center, Seongnam-si, Korea
,
Sung Pyo Hong
Division of Gastroenterology, Department of Internal Medicine, Cha Bundang Medical Center, Seongnam-si, Korea
› Author Affiliations
Further Information

Corresponding author

Joo Young Cho, MD, PhD
Division of Gastroenterology
Department of Internal Medicine
Cha Bundang Medical Center
59 Yatapro
Bundang-gu, Seongnam-si
Korea   
Fax: +82-32-7805005   

Publication History

Publication Date:
13 April 2018 (eFirst)

 

A 28-year-old man was referred to hospital with dysphagia, a symptom that had persisted for 10 years. He had recently been admitted to another clinic for aspiration pneumonia before being referred to our hospital. Gastroscopy showed a tightened esophagogastric junction (EGJ).

We developed a fluoroscopy-guided peroral endoscopic myotomy (POEM) technique ([Fig. 1], [Video 1]) using C-arm. This procedure was performed by an experienced gastroenterologist (J. Y. C), as follows. 1) A mucosal incision was made to create a submucosal tunnel entrance. 2) An indocyanine green (ICG) dye tracer was injected and an endoclip was placed below the EGJ. 3) Submucosal tunneling started 12 cm proximal to the EGJ, and intraprocedural fluoroscopy was used to document the submucosal tunnel direction toward the EGJ. 5) The greenish submucosa previously labeled with ICG was visualized. 6) Myotomy was performed. 7) Mucosal entry was closed with endoclips. After the procedure, smooth passage of the endoscope was possible.

Zoom Image
Fig. 1 Fluoroscopy-guided peroral endoscopic myotomy (POEM). a Gastroscopy revealed accumulation of a large amount of food in the lower esophagus. b Preoperative chest computed tomography showed dilation of the entire esophagus containing large quantities of food. c Barium radiograph showed the tortuous esophageal lumen with a beak-shaped appearance of the distal esophagus (sigmoid-shaped esophagus). d Indocyanine green injection with endoclip deployment was performed. e Fluoroscopy-guided POEM. f Submucosal tunneling. g Full-thickness myotomy. h Smooth endoscope passage through the esophagogastric junction.

Video 1 Fluoroscopy-guided peroral endoscopic myotomy as a treatment for achalasia.

Georg Thieme Verlag. Please enable Java Script to watch the video.

There were no immediate complications, and the patient was discharged after 10 days. The procedure duration was 60 minutes, and the myotomy length was 10 cm. After 1 month, the Eckardt symptom score had improved from 9 to 0.

POEM is a standard, widely accepted achalasia treatment [1]. However, because of its complexity, successful POEM requires advanced endoscopic skills and specialized training. Sigmoid-type achalasia poses a therapeutic challenge because of its many acute angulations before reaching the EGJ [2]. Liu et al. [3] performed open POEM as an easier and less time-consuming technique for sigmoid-shaped esophagus. Fluoroscopy-guided POEM is an efficient technique for objectively investigating anatomically challenging locations. Adequate direction of submucosal tunneling to the EGJ was confirmed by visualizing the ICG-marked greenish submucosa. Technique limitations include the requirement of an operative suite and patient exposure to small amounts of radiation. Fluoroscopic images could be used to determine submucosal tunneling direction and navigation to the EGJ, preventing accidental probe misdirection.

Endoscopy_UCTN_Code_TTT_1AO_2AD

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


#

Competing interests

None


Corresponding author

Joo Young Cho, MD, PhD
Division of Gastroenterology
Department of Internal Medicine
Cha Bundang Medical Center
59 Yatapro
Bundang-gu, Seongnam-si
Korea   
Fax: +82-32-7805005   


Zoom Image
Fig. 1 Fluoroscopy-guided peroral endoscopic myotomy (POEM). a Gastroscopy revealed accumulation of a large amount of food in the lower esophagus. b Preoperative chest computed tomography showed dilation of the entire esophagus containing large quantities of food. c Barium radiograph showed the tortuous esophageal lumen with a beak-shaped appearance of the distal esophagus (sigmoid-shaped esophagus). d Indocyanine green injection with endoclip deployment was performed. e Fluoroscopy-guided POEM. f Submucosal tunneling. g Full-thickness myotomy. h Smooth endoscope passage through the esophagogastric junction.