Open peroral endoscopic myotomy for achalasia with sigmoid-shaped esophagus

Abstract

Open peroral endoscopic myotomy for achalasia with sigmoid-shaped esophagus A 54-year-old woman sought clinical consultation because of a > 27-year history of dysphagia. She had an Eckardt score of 13 and was diagnosed with sigmoid-type achalasia (S2 type, type II) based on esophageal motility testing, upper endoscopy, barium esophagography, and clinical presentations. We investigated a technique of peroral endoscopic myotomy (POEM) performed directly without a submucosal tunnel for the treatment of achalasia, which we call open POEM (O-POEM). O-POEM was successfully performed with no procedurerelated adverse events, resulting in a post O-POEM Eckardt score of 2 ( Fig. 1, Video 1). The procedure time for O-POEM was 25.0 minutes and the length of the myotomy was 8.0 cm. Prophylactic antibiotics were given intravenously 30 minutes before O-POEM, and a nasogastric tube placement was continued for 2 days postoperatively. A E-Videos Video 1 Preoperative gastroscopy showing a dilated and tortuous esophageal lumen (S2 type) with a tightly closed cardia. A submucosal injection and mucosal incision were performed, followed by the selective myotomy of the circular muscle. After complete myotomy, smooth passage of the endoscope through the esophagogastric junction was possible with minimal resistance. Fig. 1 Open peroral endoscopic myotomy (O-POEM). a Preoperative barium radiograph showing the beak-shaped appearance of a distal esophagus (sigmoid-shaped esophagus). b Preoperative gastroscopy showing a tightly closed cardia. c, d Mucosotomy performed after submucosal saline injection. e Cutting of a circular layer of the esophagus after mucosectomy. f Postoperative gastroscopy with a relaxed cardia (greatly improved compared with the tight esophagogastric junction with lumen effacement seen in b). g Postoperative barium radiograph showing rapid passage of barium from the esophagus into the stomach. h Gastroscopic view of the postoperative cardia during follow-up revealed a healing mucosa in the area of O-POEM.