Modified technique of peroral endoscopic myotomy using transnasal ultra-slim gastroscope in a child with achalasia cardia

Post written by Amol Bapaye, MD, FASGE, FJGES, from the Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, Pune, India.


An 18-month female child presented with failure to thrive and regurgitation for 1 year. She was diagnosed with type II achalasia cardia on high-resolution manometry, and peroral endoscopic myotomy (POEM) was planned.

Owing to the patient’s small size, we encountered technical challenges that required us to modify the conventional POEM technique.

A standard gastroscope (GIF-H190; Olympus, Tokyo, Japan) with a distal attachment could not be negotiated through the patient’s cricopharynx. Therefore, an ultra-slim transnasal endoscope (GIF-XP190; Olympus) was chosen, and a custom distal attachment was fashioned from the proximal end of a 5.5-mm endotracheal tube.

In addition, standard POEM-specific knives could not be passed through the 2.2-mm working channel of the transnasal endoscope, so a 25-mm polypectomy snare (SnareMaster SD-221U-25; Olympus) and a 6F cystotome (G-Flex, Nivelles, Belgium) were used for submucosal dissection.

Additional submucosal injection was performed using the inner sheath of a needle after cutting off the needle tip, and the cystotome allowed simultaneous injection and dissection. A 6-cm posterior full-thickness myotomy was conducted using the tip of the polypectomy snare.

Finally, the mucosal incision was closed using endoclips after exchanging for a standard gastroscope without the distal attachment.

This video demonstrates the safety and efficacy of POEM in small children. Our aim is to highlight the simple and inexpensive technical modifications, especially the novel distal attachment and submucosal dissection and myotomy using the snare tip and 6F cystotome that made the procedure feasible and successful in our patient.

Although achalasia is uncommon in children of this age group, this video serves as an important guide for endoscopists who may encounter such a difficult situation in their clinical practice.

In conclusion, this article describes the novel use of in-house devices to circumvent a difficultly that could potentially decide success versus failure in an endoscopic procedure. Endoscopists worldwide can use this technique and modification when they encounter such a challenging clinical situation and thus improve the effectiveness of POEM, especially in small children.

Furthermore, this video shows that interventional endoscopy requires an endoscopist to think on his or her feet, to modify the procedural technique to suit the required circumstances, and to use the tools available in the unit efficiently and intelligently. Innovation does not necessarily need to be expensive, as is demonstrated in our video. Simple practical thinking along with the use of common tools can often enable the endoscopist to overcome the perceived challenge and achieve success in the planned procedure.

We thank VideoGIE for providing us this platform to discuss our video case and thank viewers for watching the video.


A, Child undergoing high-resolution manometry under conscious sedation. B, High-resolution manometry tracing demonstrating type II achalasia cardia.

Read the full article online.

The information presented in Endoscopedia reflects the opinions of the authors and does not represent the position of the American Society for Gastrointestinal Endoscopy (ASGE). ASGE expressly disclaims any warranties or guarantees, expressed or implied, and is not liable for damages of any kind in connection with the material, information, or procedures set forth.

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