Pull-back myotomy to prevent mucosal injury during peroral endoscopic myotomy for jackhammer esophagus

Mucosal injury is a notable perioperative complication of peroral endoscopic myotomy (POEM), occurring in 1.6%–25.8% of procedures [1] [2] [3]. Esophageal perforation caused by mucosal injury can lead to leakage of contents into the mediastinum, potentially resulting in mediastinitis [4]. Jackhammer esophagus is a hypercontractile esophageal motility disorder diagnosed using high-resolution manometry (HRM), necessitating extended myotomy in POEM [5]. Additionally, heightened caution is warranted when the length of the submucosal tunnel exceeds 13 cm, as it is associated with an elevated risk of mucosal injury [2]. Therefore, the POEM for jackhammer esophagus should be approached cautiously, considering the potential risk of mucosal injury.

Herein, we report on a 74-year-old man who underwent POEM of jackhammer esophagus. Endoscopic examination showed spastic contractions in the esophageal body impeded the passage of the scope. HRM showed hypercontractility of the esophageal body ([Fig. 1]). We performed the POEM using a Triangle Tip Knife J (Olympus, Tokyo, Japan). Hypercontraction was observed endoscopically during submucosal tunnel creation and myotomy. Initially, we started a conventional myotomy, making an incision from the muscle side to the tunnel side. However, concerns arose regarding mucosal injury due to contact between the knife and the mucosa during hypercontraction ([Fig. 2] a). Therefore, we converted to an alternative procedure termed “pull-back myotomy”, moving the Triangle Tip Knife J from the tunnel to the muscle layer ([Fig. 2] b–d, [Video 1]). This approach effectively prevented knife contact with the mucosa, even during hypercontraction. Consequently, a 19-cm myotomy was completed without causing mucosal injury. Four months after POEM, hypercontraction had disappeared, and the patient’s symptoms were improved ([Fig. 3]).

Fig. 1 Examinations before peroral endoscopic myotomy. a Normal esophageal peristalsis was not observed during endoscopy. b Abnormally strong contractions were observed. c Endoscopic ultrasonography showed 3 mm thickening of the inner circular muscle of the esophageal body. d High-resolution manometry showed hypercontractility, with the highest distal contractile integral reaching 22,488 mmHg·cm·s; over 40% of swallows had distal contractile integral values exceeding 8,000 mmHg·s·cm.

Fig. 2 Endoscopic findings during peroral endoscopic myotomy. a After creating a submucosal tunnel, conventional myotomy was initiated using the Triangle Tip Knife J from the muscle layer side to the submucosal tunnel side (white arrow). b Concerns about mucosal injury arose due to the proximity of the mucosa and muscle during strong contractions. c During the pull-back myotomy, the Triangle Tip Knife J was operated from the submucosal tunnel to the muscle layer (yellow arrow), thereby preventing mucosal injury. d Myotomy was completed without mucosal injury.

Fig. 3 Examinations after peroral endoscopic myotomy. a Endoscopy showed no abnormal contraction of the esophagus. b There were no findings of gastroesophageal reflux disease at the esophagogastric junction. c Endoscopic ultrasonography showed that the thickening of the muscle layer had disappeared in the area where the myotomy was performed (white arrow). d Abnormal contractions also disappeared on high-resolution manometry.

Pull-back myotomy to prevent mucosal injury during peroral endoscopic myotomy for jackhammer esophagus.Video 1

To the best of knowledge, there are no reports detailing specific myotomy techniques designed to prevent mucosal injury, such as the pull-back myotomy. However, large-scale studies are needed to determine the efficacy of this procedure.

Endoscopy_UCTN_Code_TTT_1AO_2AP

Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Yeniova AÖ, Yoo IK, Cho JY. Mucosal injury during per-oral endoscopic myotomy: a single-center experience. Turk J Gastroenterol 2022; 33: 985-994
• 2 Wang Y, Liu ZQ, Xu MD. et al. Clinical and endoscopic predictors for intraprocedural mucosal injury during per-oral endoscopic myotomy. Gastrointest Endosc 2019; 89: 769
• 3 Madkour A, Elfouly A, Elnahas O. et al. A novel method for intratunnel closure of mucosal injuries during peroral endoscopic myotomy using standard endoclips. Endoscopy 2023; 55: E916-E917
• 4 Shiwaku H, Inoue H, Yamashita K. et al. Peroral endoscopic myotomy for esophageal achalasia: outcomes of the first over 100 patients with short-term follow-up. Surg Endosc 2016; 30: 4817-4826
• 5 Bechara R, Ikeda H, Inoue H. Peroral endoscopic myotomy for Jackhammer esophagus: to cut or not to cut the lower esophageal sphincter. Endosc Int Open 2016; 4: E585-E588

Publication History

Article published online:
24 April 2024