Reply to Huo et al.

We read with great interest the letter of Huo et al., which commented on our case report entitled “Use of a long, stiff, overtube placed by a colonoscope to facilitate the POEM procedure for a 36-year history of achalasia with 13-cm esophageal dilation” [1]. We would like to thank the authors for their comments and suggestions.

First, the Chicago classification of this achalasia could not be described precisely because the measurement probe could not pass the cardia in the sigmoid-shaped esophagus. In this case, the cardia could not be reached even with a colonoscope, and we really think that the overtube was the key to our success in reaching the cardia and performing the myotomy.

As highlighted by Huo et al., we were technically obliged to perform a short myotomy in this long, sigmoid-shaped esophagus because we could not enter the mucosa higher in the esophagus owing to severe submucosal fibrosis.

Nevertheless, it has not been so clearly demonstrated that extended esophageal myotomy is more effective than a myotomy of shorter length in the particular case of peroral endoscopic myotomy (POEM) [2] [3]. In fact, the benefits of extended myotomy on the esophageal wall have only been demonstrated in the case of Heller’s myotomy [4] but never for POEM. As described by Teitelbaum et al. [3], POEM is effective for the improvement of esophageal distensibility immediately after myotomy of the cardia, and this distensibility is not improved by extended myotomy on the esophageal muscle. Conversely, in Heller myotomy, the section of muscle in the cardia was not effective for the improvement of distenstibility, and extended myotomy was needed to achieve this improvement. These results were confirmed in a clinical evaluation of short myotomy outcomes, with a mean total myotomy length of 5.4 cm [2], with very good effectiveness and safety.

Thus, these different results of short-length efficacy combined with the inability to perform an extended tunnel because of severe fibrosis in our patient, led us to perform the short myotomy in an effort to improve the patient’s quality of life. The patient’s Eckardt score reduced dramatically after the procedure, and therefore this case is a new demonstration of the potential effectiveness of short myotomy for achalasia using POEM.

• References

• 1 Unn K, Chhorn P, Rivory J et al. Use of a long, stiff, overtube placed by a colonoscope to facilitate the POEM procedure for a 36-year history of achalasia with 13-cm esophageal dilation. Endoscopy 2016; 48: E172-E173
• 2 Wang J, Tan N, Xiao Y et al. Safety and efficacy of the modified peroral endoscopic myotomy with shorter myotomy for achalasia patients: a prospective study. Dis Esophagus 2015; 28: 720-727
• 3 Teitelbaum EN, Soper NJ, Pandolfino JE et al. An extended proximal esophageal myotomy is necessary to normalize EGJ distensibility during Heller myotomy for achalasia, but not POEM. Surg Endosc 2014; 28: 2840-2847
• 4 Wright AS, Williams CW, Pellegrini CA et al. Long-term outcomes confirm the superior efficacy of extended Heller myotomy with Toupet fundoplication for achalasia. Surg Endosc 2007; 21: 713-718