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

Our patient had a tight wrap after laparoscopic Heller myotomy and fundoplication for achalasia cardia. Repeat balloon dilatation of the lower esophageal sphincter had failed to provide adequate symptom response. There was confusion whether the dysphagia was because of recurrent achalasia or the tight wrap.

We addressed both issues of possible recurrent achalasia and the tight wrap with a single endoscopic procedure. This video case demonstrates the technique of endoscopic wrap release by intraperitoneal dissection using a natural orifice transluminal endoscopic surgery approach after peroral endoscopic myotomy.

Persistent dysphagia can occur because of a tight wrap after laparoscopic Heller myotomy plus fundoplication. Although conventional treatment has been repeat surgery and taking down of the wrap, this is invasive and has reported morbidity. To our knowledge, this video is the first instance when, after peroral endoscopic myotomy, the wrap was released endoscopically using a natural orifice transluminal endoscopic surgery approach. This may avoid repeat surgery in such patients.

Endoscopists should be aware that recurrent dysphagia after laparoscopic Heller myotomy with Dor fundoplication can be because of a tight wrap and not only recurrence of achalasia. In addition, endoscopists should have the knowledge that this problem can be addressed endoscopically, and repeat surgery may not always be required. This video can help advanced endoscopists learn and offer this procedure to patients who present with a similar clinical situation.

EGD images in retroflexion demonstrating (A) tight fundic wrap before the procedure and (B) released fundic wrap after the procedure.

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