Peroral endoscopic myotomy (POEM) is a well-established third-space endoscopic technique
that can be technically challenging when used to treat a cricopharyngeal bar, even
for experienced operators, due to the limited working space in the hypopharynx and
upper esophageal sphincter [1]
[2]. Here we propose the use of saline immersion to improve the technical success rate
of the procedure.
We present the case of a 58-year-old woman with a history of inclusion body myositis
for 10
years and dysphagia due to a symptomatic cricopharyngeal bar for 3 years ([Fig. 1]). We performed cricopharyngeal POEM under general anesthesia. Once the cricopharyngeal
bar was identified, thermal markings were made at the entry point <1 cm proximally
using a
triangle-tip knife. A submucosal bleb was created using indigo carmine and saline,
followed by a
transverse mucosotomy. A short submucosal tunnel was created using spray coagulation.
To gain
entry into the tunnel, facilitate further dissection, and ultimately perform the myotomy,
saline
immersion was used to lift the mucosa away from the cricopharyngeal muscle ([Video 1], [Fig. 2]). The myotomy was extended 2 cm beyond the cricopharyngeal muscle to ensure complete
division. The resistance at the hypopharynx was eliminated. The mucosotomy was closed
longitudinally using four hemoclips ([Fig. 3]). After the dysphagia had resolved and the esophagogram showed no leaks, the patient
was
discharged on day 3. Barium swallow performed 15 days after the procedure showed resolution
of
the cricopharyngeal bar and complete passage of barium ([Fig. 4]). At the 1 month follow-up, the patient reported resolution of her dysphagia.
Fig. 1 Barium swallow study showing a cricopharyngeal bar (red arrow) in a 58-year-old woman
with dysphagia.
Fig. 2 Endoscopic image of underwater tunnel and the uncut cricopharyngeal muscle in a 58-year-old
woman with a cricopharyngeal bar.
Fig. 3 Four hemoclips were applied to repair the mucosotomy during cricopharyngeal peroral
endoscopic myotomy.
Fig. 4 Barium swallow study performed after the cricopharyngeal peroral endoscopic myotomy
showing resolution of the cricopharyngeal bar and complete passage of barium.
Application of the underwater technique to separate tissues during a successful cricopharyngeal
per oral myotomy in a 58-year-old woman with a cricopharyngeal bar.Video 1
Underwater endoscopic mucosal resection, used for colorectal polyps as early as 2012,
leverages the inherent density differences in tissue planes to facilitate tissue separation
[3]. Given the technical difficulty of performing cricopharyngeal POEM, we believe that
underwater endoscopic mucosal resection can enable easier entry into the tunnel and
facilitate more complete myotomy.
Endoscopy_UCTN_Code_TTT_1AO_2AG_3AZ
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