Clin Endosc.  2013 Mar;46(2):161-167. 10.5946/ce.2013.46.2.161.

Peroral Endoscopic Myotomy for Treatment of Achalasia: Initial Results of a Korean Study

• Lee BH
• Shim KY
• Hong SJ
• Bok GH
• Cho JH
• Lee TH
• Cho JY

• KMID: 1805298
• DOI: http://doi.org/10.5946/ce.2013.46.2.161

Abstract

BACKGROUND/AIMS
Achalasia is a rare esophageal motility disorder. Recently, a novel endoscopic technique, peroral endoscopic myotomy (POEM), was introduced as an alternative treatment for achalasia. We report the results and short term outcomes of POEM for patients with achalasia.
METHODS
POEM was performed in 13 patients with achalasia. The procedure consisted of creating a submucosal tunnel followed by endoscopic myotomy of circular muscle bundles. The mucosal entry was closed by conventional hemostatic clips. A validated clinical symptom score (Eckardt score) and high resolution manometry were used to evaluate the outcomes.
RESULTS
Both the clinical score of achalasia, as well as the resting lower esophageal sphincter (LES) pressure, were significantly reduced after POEM. Mean posttreatment Eckardt score was 0.4+/-0.7, compared to 6.4+/-1.9 prior to the treatment (p=0.001). The mean pretreatment and posttreatment LES pressure was 30.3 and 15.3 mm Hg, respectively (p=0.007). Following POEM, symptomatic relief from dysphagia without reflux symptoms was observed in all patients (13/13). No serious complications related to POEM were encountered.
CONCLUSIONS
Based upon our initial experience, the authors believe that POEM is a feasible, safe, and effective treatment and may possibly substitute established treatments of refractory achalasia.

Keyword

Esophageal achalasia; Peroral endoscopic myotomy; High resolution manometry

MeSH Terms

Deglutition Disorders
Esophageal Achalasia
Esophageal Motility Disorders
Esophageal Sphincter, Lower
Humans
Manometry
Muscles

Figure

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  Fig. 1 Esophageal high resolution manometry. Lower esophageal sphincter (LES) pressure was increased. If swallowing was induced, relaxation of LES was not seen and peristalsis was absent. Type I achalasia exhibited minimal pressurization of the esophageal body.

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  Fig. 2 (A) A 2-cm longitudinal incision was performed on the mucosal surface for initiation of an entry point into the submucosal space. (B) In the submucosal space, an endoscopic tunnel is created primarily by careful electrocoagulation using a Dual Knife. (C) Endoscopic myotomy was begun 2 cm distal to the mucosal entry using Dual Knife and Hook Knife. (D) After dissection of the circular muscle bundles, outer longitudinal muscle bundles were endoscopically identified. (E) Completion of endoscopic myotomy. Circular muscle bundles were dissected and the 10-cm myotomy was completed. (F) After complete myotomy, the mucosal entry site is closed using standard endoscopic clips.

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  Fig. 3 (A) Endoscopic findings of achalasia. Note dilatation in the middle esophagus and retention of water in the lower esophagus. (B) Esophagogram. Note achalasia with esophageal dilatation with an air-fluid level, tapering at the esophagogastric junction, providing a "bird beak" narrowing appearance.

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  Fig. 4 (A) Esophagogram after peroral endoscopic myotomy (POEM): barium passed and was excreted quickly through lower esophageal sphincter (LES). (B) High resolution manometry after POEM (3 months later): LES pressure was decreased, and if swallowing was induced, relaxation and passage of LES was seen.

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