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

Hybrid Peroral Endoscopic Myotomy for Achalasia with Prior Treatment Failure

Affiliations
  • 1Division of Gastroenterology, Department of Internal Medicine, Cha Bundang Medical Center, Seongnam, Korea
  • 2Division of Gastroenterology, Department of Internal Medicine, Tokat Gaziosmanpaşa University, Tokat, Turkey

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

  • Fig. 1. Endoscopy before the procedure.

  • Fig. 2. Barium esophagogram before the procedure.

  • 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.

  • Fig. 4. Endoscopy after the procedure.

  • Fig. 5. Barium esophagogram after the procedure.


Reference

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