A 15-year old boy was diagnosed with type II achalasia cardia at our hospital and
peroral endoscopic myotomy (POEM) was performed by the posterior route (5 o’clock).
The standard steps of the POEM procedure included: mucosal incision, submucosal tunneling,
myotomy, and closure of the incision with endoclips [1]. We incorporated an important modification in our myotomy technique in order to
preserve the oblique muscle fibers close to the gastroesophageal junction.
In this technique, we identified two penetrating vessels at the gastric end of submucosal
tunnel ([Fig. 1 a, b]). These vessels have been described as a marker of the junction between the circular
and oblique muscle fibers [2]. The second penetrating vessel was not coagulated and served as a guide for later
identification of the oblique muscle fibers. Myotomy was performed in the usual fashion
until the gastroesophageal junction was reached. Subsequently, the direction of the
myotomy was re-adjusted in such a fashion that it was possible to selectively avoid
severing the oblique muscle fibers ([Fig. 1 c]). A lax gastroesophageal junction could be appreciated after the POEM procedure
([Fig. 2]). Finally, the mucosal incision was closed with the standard technique using multiple
endoclips ([Video 1]).
Fig. 1 Endoscopic views during peroral endoscopic myotomy showing: a the first penetrating vessel, which was revealed during submucosal tunneling towards
the gastric side; b the second penetrating vessel marking the junction between the oblique (left) and
circular muscle fibers (right), with the knife pointing towards the oblique muscle
fibers; c endoscopic myotomy being performed towards the right of the second penetrating vessel,
thereby preserving the oblique muscle fibers.
Fig. 2 Endoscopic appearance after completion of the myotomy showing the lax gastroesophageal
junction.
Video 1 Video demonstrating the technique to preserve the oblique muscle fibers during peroral
endoscopic myotomy.
POEM has emerged as a safe and efficacious treatment modality for achalasia cardia,
with encouraging results in the pediatric population as well [3]; however, gastroesophageal reflux disease (GERD) is a major concern after POEM [4]. The oblique fibers form an important component of the anti-reflux barrier and are
usually severed during posterior POEM. In this video, we demonstrate a novel technique
for POEM in which the oblique fibers are preserved to prevent GERD.
Endoscopy_UCTN_Code_TTT_1AO_2AN
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