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 [1] [2]. POEM with simultaneous submucosal and muscle dissection (POEM-SSMD) has been described for achalasia with severe adhesions in the submucosa of the cardia [3]. 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.

Fig. 1 A narrowed segment in the esophagus is revealed on: a esophagogastroduodenoscopy, with the standard endoscope unable to pass through the narrowing; b an endoscopic ultrasonography (EUS) image, with a thick band of muscle seen.

Fig. 2 Esophagram images: a before peroral endoscopic myotomy (POEM), showing strong contractions and a narrowed lumen; b on day-1 post-POEM, showing an improvement in contrast emptying.

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 [4] [5], 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.

Fig. 3 Endoscopic image during peroral endoscopic myotomy with simultaneous submucosal and muscle dissection.

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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• References

• 1 Inoue H, Minami H, Kobayashi Y. et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy 2010; 42: 265-271
• 2 Khashab MA, Messallam AA, Onimaru M. et al. International multicenter experience with peroral endoscopic myotomy for the treatment of spastic esophageal disorders refractory to medical therapy. Gastrointest Endosc 2015; 81: 1170-1177
• 3 Chai NL, Li HK, Linghu EQ. et al. Consensus on the digestive endoscopic tunnel technique. World J Gastroenterol 2019; 25: 744-776
• 4 Tanaka S, Kawara F, Toyonaga T. et al. Two penetrating vessels as a novel indicator of the appropriate distal end of peroral endoscopic myotomy. Dig Endosc 2018; 30: 206-211
• 5 Tanaka S, Toyonaga T, Kawara F. et al. Novel per-oral endoscopic myotomy method preserving oblique muscle using two penetrating vessels as anatomic landmarks reduces postoperative gastroesophageal reflux. J Gastroenterol Hepatol 2019; 34: 2158-2163