Post written by Zaheer Nabi, MD, DNB, from the Asian Institute of Gastroenterology, Hyderabad, India.
This video case describes a novel technique of peroral endoscopic myotomy (POEM) in a patient with recurrence of symptoms after Heller’s myotomy. In this case, we performed POEM by posterior route ie, 5 o’clock. After completing myotomy, we performed a second myotomy parallel to the first myotomy and resected the muscle tissue between the 2 myotomies. A wide defect between the cut ends of muscle could be appreciated after the completion of the procedure.
Achalasia cardia cannot be cured with the current treatment modalities, which aim to reduce the symptoms by relieving outflow obstruction at gastroesophageal junction. Therefore, relapse of symptoms may occur after any treatment modality used for achalasia. Heller’s myotomy is considered a durable treatment modality for achalasia. However, recurrent symptoms may arise due to multiple factors like progression of the disease, incomplete myotomy, and fibrosis at the myotomy site. We presumed that if myotomy edges are separated widely during POEM, recurrence due to fibrosis may be reduced. With this thought, we performed “myectomy” at and below the gastroesophageal junction in order to widen the gap between the muscle ends. The technique of myectomy is easy and does not require any special accessories.
POEM was introduced by Prof. Inoue about a decade back. Since then, there have been no major technical modifications in the POEM procedure. The success rates of POEM may be lower in cases with symptom relapse after Heller’s myotomy. Therefore, in special scenarios like this, we need to think out of the box to improve the outcomes of POEM and reduce the requirement of further interventions. Since, the technique of “myectomy” appears easy and reproducible it may be worth evaluating it further.
In addition to creating a wider defect, “myectomy” also offers a substantial amount of muscle tissue, which can be utilized for improving our current understanding in the pathophysiologic mechanisms of the disease.
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