Clin Endosc.  2020 Mar;53(2):232-235. 10.5946/ce.2019.067.

Two-Stage Peroral Endoscopic Myotomy for Sigmoid-Type Achalasia

• Kim HS
• Kim HK
• Ko WJ

• KMID: 2500892
• DOI: http://doi.org/10.5946/ce.2019.067

Abstract

Peroral endoscopic myotomy (POEM) has been recently considered as the first treatment option for achalasia. The standard POEM procedures are often successful in most patients, but sometimes technical challenges are encountered. We report a new technique that is divided between two tunneling sites in the esophagus for sigmoid-type achalasia. A 40-year-old male patient with dysphagia for 10 years was diagnosed with a sigmoid-shaped esophagus at our hospital. We devised a two-stage myotomy technique to treat sigmoidtype achalasia. The myotomy was first performed in the upper part of the greater flexion area and then in the lower part of the flexion. We termed this method “two-stage POEM”, which was successfully performed without any complications. This new POEM method can also be used to improve symptoms in patients with achalasia who have a structural deformity that may result in a high change of treatment failure.

Keyword

Esophageal achalasia; Esophageal motility disorders; Myotomy; Peroral endoscopic myotomy

Figure

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  Fig. 1. (A) Preoperative barium esophagography showing the remaining contrast medium, which was about 13 cm in length with a bird beak appearance in the esophagus (sigmoid-shaped esophagus). (B) High-resolution manometry showing the absence of peristalsis and no pressurization within the esophageal body as well as high integrated relaxation pressure.

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  Fig. 2. The peroral endoscopic myotomy procedure. (A) The first submucosal tunnel was made after submucosal saline injection using an endoscopic knife at the upper part of the greater flexion area. (B) Myotomy was then performed at this area. (C) The second submucosal tunneling was performed at the lower part of the flexion. (D) A second myotomy was performed.

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  Fig. 3. After three days of the peroral endoscopic myotomy procedure, follow-up Barium esophagography showed barium contrast agents rapidly passing the esophagus.

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