Post written by Carlos Robles-Medranda, MD, from the Instituto Ecuatoriano de Enfermedades Digestivas (IECED), Guayaquil, Ecuador.

In this video case presentation, we illustrate a compelling clinical scenario involving an underweight 2-year-old girl who presented with a confirmed diagnosis of achalasia. In a noteworthy facet, parental refusal for surgical intervention prompted the consideration of an alternative endoscopic approach, peroral endoscopic myotomy (POEM).

A Pentax EB-1970K bronchoscope (Pentax Medical, Tokyo, Japan) was complemented by a crafted disposable dissection cap formed from an endotracheal tube. This scope was integrated with an adapted suction and irrigation system. For key elements of the intervention, such as mucosal incision, dissection, coagulation, and full-thickness myotomy, a 2.3-mm x 1.9-m T-type HybridKnife (Erbe Elektromedizin GmbH, Tübingen, Germany) was used. The working channel of the bronchoscope allowed the use of the latter.

Remarkably, at 1-month follow-up assessment, the patient exhibited marked symptomatic improvement. At 15-month follow-up, she remained asymptomatic and displayed a substantial 4-kg weight gain. Objective evaluation through EGD and barium esophagogram confirmed achalasia resolution.

This video is of paramount importance because of the exceptional challenges of the smaller esophageal diameter in pediatric patients during endoscopic procedures. The diameter of the conventional working channel of standard endoscopic scopes often hinders the effective use of adult-sized instruments, making procedures intricate and difficult.

This presentation showcases a pivotal solution with the use of a bronchoscope, which features a smaller tube diameter and a 2.8-mm working channel, allowing for the successful use of adult instruments. This demonstrates a novel approach to pediatric endoscopy and highlights its clinical significance by expanding the indications of the scope and ultimately enhancing the quality of care for pediatric patients facing esophageal conditions.

This case serves as a highly valuable educational resource, shedding light on an innovative and secure approach to conducting POEM in pediatric patients. By disseminating this experience, our objective is to broaden the spectrum of available strategies in the treatment of pediatric achalasia.

Assessment of esophageal emptying on barium esophagogram before peroral endoscopic myotomy showed a bird’s beak sign.

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