A 36-year-old woman suffered thoracic pain and dysphagia following a barbecue 6 months
earlier. Gastroscopy showed an ulcer in the lower esophagus. The thoracic pain disappeared
after taking proton pump inhibitors (PPIs) for a week, but dysphagia continued. Repeat
gastroscopy showed a thickened and rigid lower esophageal wall and esophageal stricture
([Fig. 1 a]). The stricture was about 4.0 cm from the cardia. Endoscopic biopsy diagnosed inflammation.
Esophagography showed severe stricture in the lower esophagus ([Fig. 2 a]). Thoracic computed tomography showed a thickened lower esophageal wall, and endoscopic
ultrasonography showed thickening of the muscularis propria in the lower esophagus
([Fig. 3]), without manifestation of tumors. The patient continued to take PPIs and underwent
three sessions of endoscopic dilation, without success; she lost 8.0 kg in weight.
Fig. 1 Gastroscopy. a Pre-procedure, showing a thickened and rigid lower esophageal wall and a stricture.
b At follow-up, showing that the incision had healed well, with only mild stricture
remaining.
Fig. 2 Esophagography. a Pre-procedure, showing severe stricture of the lower esophagus. b At follow-up, showing significant improvement, with only mild stricture.
Fig. 3 Endoscopic ultrasonography showed a thickened muscularis propria in the lower esophagus.
We performed open peroral endoscopic myotomy (O-POEM) ([Video 1]). The mucosal and circular muscle layers of the stricture were incised completely
without submucosal tunnel creation ([Fig. 4]), and with the upper and lower edge incisions extending about 2.0 cm beyond the
stricture.
Video 1 The lower esophagus was rigid and strictured, and the mucosal and circular muscle
layers of the stricture were incised completely without submucosal tunnel creation.
Fig. 4 The mucosal and circular muscle layers of the stricture were incised completely without
submucosal tunnel creation.
The patient recovered uneventfully after endoscopic treatment and gradually returned
to a normal diet. Her body weight had increased by 4.0 kg at 6 months after treatment.
Follow-up esophagography showed that the stricture had significantly improved post-procedure
([Fig. 2 b]). Follow-up gastroscopy showed that the original esophageal incision had healed
well and the lumen was only mildly strictured ([Fig. 1 b]), with smooth passage of the endoscope.
Endoscopic balloon dilation [1] or stenting [2] is an effective treatment for benign esophageal stricture. Radial incision and cutting
[3] can also be performed. Due to the poor effect of balloon dilation, the rigid wall,
and the presence of stricture, we performed O-POEM for this patient. O-POEM is a safe
and effective treatment for achalasia [4], as well as an effective therapy for benign esophageal stricture.
Endoscopy_UCTN_Code_TTT_1AO_2AN
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