Clin Endosc.  2021 Jan;54(1):127-130. 10.5946/ce.2020.013.

Hybrid Peroral Endoscopic Myotomy for Achalasia with Prior Treatment Failure

• Yoo IK
• OzgurYeniova A
• Cho JY

• KMID: 2512318
• DOI: http://doi.org/10.5946/ce.2020.013

Abstract

Achalasia is a neurodegenerative motility disorder caused by enteric neuron damage in the lower esophageal sphincter. Peroral endoscopic myotomy (POEM) is a standard treatment method for achalasia. Previous treatment modalities may affect the outcome of POEM as they cause submucosal fibrosis. We report a new technique called “hybrid POEM” for the treatment of patients with achalasia who had been previously treated with pneumatic balloon dilatation. We performed two techniques of POEM simultaneously, the standard POEM for the upper part of the submucosal tunnel and open POEM for the stenotic part of the esophagogastric junction. We dissected the mucosa and submucosa, and performed myotomy simultaneously. We overcame submucosal fibrosis of the esophagogastric junction, which was caused by the previous hybrid POEM treatment. The risks of mucosal incision and technical challenge of submucosal tunneling for the fibrotic area may be reduced by hybrid POEM.

Keyword

Achalasia; Esophagus; Peroral endoscopic myotomy

Figure

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  Fig. 1. Endoscopy before the procedure.

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  Fig. 2. Barium esophagogram before the procedure.

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  Fig. 3. Hybrid peroral endoscopic myotomy (POEM). (A) Endoscopy reveals very tight esophagogastric junction (EGJ). (B) Barium radiograph showing no passage after the 5 minute delayed phase. (C) Submucosal injection was given 7 cm proximal to the EGJ. (D) Careful injection and dissection on the EGJ. (E) Open POEM around the stenotic part. (F) Standard POEM in the tunnel. (G) Fully covered esophageal stent insertion. (H) Entry site clipping.

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  Fig. 4. Endoscopy after the procedure.

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  Fig. 5. Barium esophagogram after the procedure.

Reference

1. Zaninotto G, Leusink A, Markar SR, et al. Management of achalasia in 2019. Curr Opin Gastroenterol. 2019; Apr. 24. [Epub]. https://doi.org/10.1097/MOG.0000000000000544.

2. Inoue H, Minami H, Kobayashi Y, et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy. 2010; 42:265–271.

3. Wu QN, Xu XY, Zhang XC, et al. Submucosal fibrosis in achalasia patients is a rare cause of aborted peroral endoscopic myotomy procedures. Endoscopy. 2017; 49:736–744.

4. Nabi Z, Ramchandani M, Chavan R, et al. Peroral endoscopic myotomy in treatment-naïve achalasia patients versus prior treatment failure cases. Endoscopy. 2018; 50:358–370.

5. Sharata A, Kurian AA, Dunst CM, Bhayani NH, Reavis KM, Swanström LL. Peroral endoscopic myotomy (POEM) is safe and effective in the setting of prior endoscopic intervention. J Gastrointest Surg. 2013; 17:1188–1192.

6. Liu W, Wu CC, Hu B. Open peroral endoscopic myotomy for achalasia with failed Heller myotomy. Dig Endosc. 2018; 30:268–269.

7. Liu W, Zeng HZ, Chen HL, Wu CC, Ye LS, Hu B. Open peroral endoscopic myotomy (O-POEM) for the treatment of achalasia. Dis Esophagus. 2017; 30:1–2.

8. Liu W, Zeng XH, Yuan XL, et al. Open peroral endoscopic myotomy for the treatment of achalasia: a case series of 82 cases. Dis Esophagus. 2019; 32:1–7.