Post written by Zaheer Nabi, MD, DNB, from the Asian Institute of Gastroenterology, Hyderabad, India.

In this video case, we demonstrated the technique of peroral endoscopic myotomy (POEM) in a case with Jackhammer esophagus. The highlight of the video is the selection of the appropriate length of esophageal myotomy using high-resolution esophageal manometry. The point of initiation of myotomy in this case was estimated by confirming the proximal end of spastic contractions on esophageal manometry. The total length of required esophageal myotomy was calculated by subtracting the distance to onset of high-amplitude contractions from the distance to gastroesophageal junction (GEJ). POEM was subsequently performed in the standard fashion. The myotomy was extended up to 2-cm beyond GEJ. Post myotomy, there was complete resolution of symptoms as well as pre-POEM manometry abnormalities.

Spastic esophageal motility disorders of the esophagus include type III achalasia, Jackhammer esophagus, and diffuse esophageal spasm. Unlike type I and II achalasia where a short myotomy is usually sufficient, longer esophageal myotomies are required in spastic motility disorders. It is crucial to select the appropriate length of esophageal myotomy in these cases in order to avoid residual symptoms due to inadequate myotomy. Although, endoscopy and barium esophagogram can provide a clue regarding the approximate length of myotomy esophageal manometry offers with better estimates about the point of initiation of myotomy. Our assumption is supported by the complete resolution of spastic esophageal contractions in the esophageal manometry after POEM in the present case.

High-resolution manometry is an indispensable tool in diagnosing as well as categorizing the type of esophageal motility disorders. In addition, manometry also aids in selecting the length of myotomy in cases with spastic esophageal motility disorders. Another learning point from this video case is the fixation of distal attachment to the endoscope. The distal attachment may get dislodged in the spastic tunnel if not adequately secured at the onset of the procedure.

In contrast to idiopathic achalasia, GEJ is usually spared in cases with non-achalasia spastic motility disorders of esophagus like Jackhammer esophagus and diffuse esophageal spasm. The decision to include GEJ into myotomy should be carefully weighed against the risk of gastroesophageal reflux (GERD) after POEM. Although, we performed sling-fiber preserving myotomy along gastric side to prevent GERD after POEM reflux esophagitis, and increased esophageal acid exposure were evident on follow-up evaluation.

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