Peroral endoscopy myotomy (POEM) is widely known as a treatment modality for achalasia
and its use has been expanding to other spastic esophageal motility disorders [1]
[2]. POEM with simultaneous submucosal and muscle dissection (POEM-SSMD) has been described
for achalasia with severe adhesions in the submucosa of the cardia [3]. We present a challenging case, in which tunneling within the submucosa alone before
the myotomy was not possible owing to spastic contractions in the mid-esophagus.
A 46-year-old woman presented with a long history of dysphagia, with worsening symptoms
and chest pain since the previous year. Esophagogastroduodenoscopy with a standard
endoscope showed narrowing at the level of the tracheal bifurcation and it was impossible
for the scope to traverse the narrowing ([Fig. 1 a]). An endoscopic ultrasonography (EUS) examination showed a thick band of muscle
([Fig. 1 b]). It was possible to pass a nasal endoscope beyond the level of the narrowing and
this revealed several diverticula in the esophagus, along with strong contractions.
An esophagram showed abnormal esophageal contractions throughout, with a narrowed
lumen ([Fig. 2 a]). High resolution manometry was inconclusive because of the difficulty in placement
of the catheter.
Fig. 1 A narrowed segment in the esophagus is revealed on: a esophagogastroduodenoscopy, with the standard endoscope unable to pass through the
narrowing; b an endoscopic ultrasonography (EUS) image, with a thick band of muscle seen.
Fig. 2 Esophagram images: a before peroral endoscopic myotomy (POEM), showing strong contractions and a narrowed
lumen; b on day-1 post-POEM, showing an improvement in contrast emptying.
The patient was diagnosed with spastic esophageal disorder and underwent POEM ([Video 1]). The mucosal entry was created with a 2-cm longitudinal incision at the 5-o’clock
position using a FlushKnife BT (Fujifilm) after submucosal injection. Submucosal dissection
was performed to create the submucosal tunnel. As we approached the tight junction
with a narrowed tunnel, proceeding with submucosal tunneling alone was not possible.
Instead, simultaneous submucosal and muscle dissection had to be performed, which
eventually opened up the tunnel ([Fig. 3]). Submucosal tunneling was continued until two penetrating vessels were seen, indicating
the distal end of the POEM [4]
[5], and the endoscopic myotomy was completed once the penetrating vessels were reached.
A standard endoscope was then passed smoothly through into the stomach. The mucosal
entry site was closed with endoclips.
Video 1 Peroral endoscopic myotomy with simultaneous submucosal and muscle dissection (POEM-SSMD)
in a tunnel that was narrowed by spastic esophageal contractions.
Fig. 3 Endoscopic image during peroral endoscopic myotomy with simultaneous submucosal and
muscle dissection.
An esophagram on day 1 after the procedure showed an improvement in contrast emptying
([Fig. 2 b]). The patient reported significant improvement in her symptoms 3 months later.
Adopting a method of simultaneous submucosal and muscle dissection in a tunnel narrowed
because of spastic contractions is feasible to allow successful completion of POEM.
Endoscopy_UCTN_Code_TTT_1AO_2AJ
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