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.
Fig. 1 Barium esophagram before the procedure.
Fig. 2 Endoscopy before the procedure.
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.
Fig. 3 The submucosal tunnel could not be established due to severe submucosal fibrosis.
Fig. 4 Full-thickness myotomy in the mediastinal tunnel.
Mediastinal dissection and tunneling.Video 1
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]).
Fig. 5 Endoscopy after the procedure.
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
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