Retrograde navigational tunnel technique in peroral endoscopic myotomy for sigmoid-type achalasia

Standard peroral endoscopic myotomy (POEM) techniques are effective for typical achalasia [1] [2] [3] [4]; however, limitations are encountered when treating the sigmoid type owing to its complex anatomy. Here, we introduce a novel retrograde navigational tunnel technique in POEM that aims to address these challenges.

A 31-year-old man was admitted to our hospital with a history of postprandial choking sensations for 5 years. Upon admission, a barium meal showed that the esophagus was diffusely dilated with a beak-like appearance at the lower end of the cardia ([Fig. 1] a). We chose to perform POEM after undertaking multidisciplinary consultation and obtaining consent from the patient ([Video 1]). The procedure was performed with the patient under general anesthesia with endotracheal intubation. A triangular knife was used throughout the surgical procedure. The lower end of the esophagus exhibited a sigmoid contortion and the cardia was seen to be closed ([Fig. 1] b). First, a submucosal injection was administered 30 cm from the incisors to establish the tunnel entrance ([Fig. 2] a). Second, a retrograde submucosal injection was performed from the cardia to the tunnel entrance ([Fig. 2] b). Third, submucosal dissection was performed in the tunnel to navigate from the entrance to 3 cm below the cardia ([Fig. 2] c,d). Both the annular and longitudinal muscles were incised in the tunnel ([Fig. 2] e). Hemostasis was achieved using hot forceps, and the tunnel entrance was closed with metal clamps ([Fig. 2] f). The operation was successfully completed in 47 minutes, without any complications being experienced.

Fig. 1 The appearance of sigmoid-type achalasia on: a barium swallow, showing a diffusely dilated esophagus with a beak-like appearance at the lower end of the cardia; b endoscopic view, showing sigmoid contortion of the lower esophagus and closed cardia.

The navigational tunnel technique is used during peroral endoscopic myotomy for a patient with sigmoid-type achalasia.Video 1

Fig. 2 Endoscopic images during the treatment of sigmoid-type achalasia by the navigational tunnel technique for peroral endoscopic myotomy showing: a the established tunnel entrance; b submucosal injection being performed in retrograde fashion from the cardia to the tunnel entrance; c the submucosal dissection navigation route at the flexion; d establishment of the submucosal tunnel; e incision of the annular and longitudinal muscles; f closure of the tunnel entrance with metal clips.

Postoperatively, the patient was fasted and given anti-infection therapy; he was discharged 3 days after the surgery. At 12-month follow-up, the patient had had no recurrence of his choking after eating.

The retrograde navigational tunnel technique in POEM for sigmoid-type achalasia offers two major advantages: (i) reduced surgical time because of continuous submucosal injection; (ii) enhanced accuracy in tunnel navigation, minimizing disorientation during submucosal stripping. In conclusion, the retrograde navigational tunnel technique in POEM is a viable and effective approach for the treatment of sigmoid-type achalasia.

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Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Ujiki MB, VanDruff VN. Peroral endoscopic myotomy for achalasia. World J Surg 2022; 46: 1542-1546
• 2 Parsa N, Friedel D, Stavropoulos SN. POEM, GPOEM, and ZPOEM. Dig Dis Sci 2022; 67: 1500-1520
• 3 Rolland S, Paterson W, Bechara R. Achalasia: Current therapeutic options. Neurogatroenterol Motil 2023; 35: e14459
• 4 Gong F, Li Y, Ye S. Effectiveness and complication of achalasia treatment: A systematic review and network meta-analysis of randomized controlled trials. Asian J Surg 2023; 46: 24-34

Publication History

Article published online:
09 April 2024