Peroral endoscopy myotomy (POEM) is now well accepted as primary treatment for achalasia
[1]
[2]
[3]. It is also effective after failed Heller myotomy [4] and can be repeated when symptoms recur [5].
In patients with advanced sigmoid-type achalasia, in addition to failure of relaxation
at the lower esophageal sphincter (LES), there may be an additional dynamic obstruction
of the distal esophagus due to an acute angulation ([Fig. 1]). This will redirect the flow of food backwards and inferiorly, which can potentially
aggravate the downward bend of the esophagus till it goes below the level of the LES,
further worsening food stasis. A real-time dynamic esophagogram is needed to demonstrate
this dynamic obstruction. In such cases, myotomy of the LES alone is inadequate, and
an additional short myotomy to reduce this acute angulation is needed in order to
change flow dynamics and allow free passage of food distally ([Fig. 1]).
Fig. 1 Esophagogram before and after peroral endoscopic myotomy (POEM) combined with curve
cutting. The red line indicates the level of the lower esophageal sphincter. The blue
and yellow arrows indicate the lumen obstructive curves, visible as sharp notches
in the barium swallow. After POEM and curve myotomy, the esophagus looks shortened.
We report three cases of symptomatic advanced sigmoid-type achalasia with an acute
dynamic angulation at the distal esophagus causing lumen obstruction that were treated
successfully with an additional curve cutting myotomy during POEM.
The first case was a 60-year-old man with type 1 achalasia who had previously been
treated by balloon dilation. The second case was a 53-year-old woman with type 1 achalasia
who had previously undergone balloon dilation and two Heller myotomy procedures. The
third case was a 73-year-old woman with previous balloon dilation, botox injection,
and POEM. Real-time esophagograms demonstrated the obstruction at the LES and at the
acute dynamic angulation of the distal esophagus caused by the sigmoid-type morphology.
Standard POEM was combined with a short proximal curve myotomy. Post myotomy, the
barium esophagogram demonstrated resolution of the obstruction ([Video 1]).
Video 1 Dynamic barium esophagogram before and after peroral endoscopic myotomy combined
with curve cutting.
Our report illustrates the importance of careful preprocedural assessment of advanced
sigmoid-type achalasia using dynamic real-time esophagogram to ascertain the nature
of obstruction, and the value of additional curve cutting myotomy to relieve the dynamic
esophageal obstruction.
Endoscopy_UCTN_Code_TTT_1AO_2AJ
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