A POEM Begins with a Lump in the Throat: An Emerging Treatment for Achalasia

Abstract

Purpose: Achalasia is an esophageal motility disorder characterized by incomplete lower esophageal sphincter (LES) relaxation, increased LES tone, and lack of peristalsis of the esophagus. A new procedure known as peroral endoscopic myotomy (POEM) is an incisionless procedure to treat esophageal achalasia, totally performed by endoscopy. We present a case of a patient who was successfully treated with this novel procedure. A 46-year-old male with symptoms of dysphagia to solid foods and recurrent regurgitation was referred to our institution for further management. The patient denied odynophagia, and admitted to halitosis and coughing, which was worse at night. EGD demonstrated no structural deformities, and a upper GI series revealed focal narrowing at the distal esophagus. An esophageal manometry demonstrated abnormally increased resting pressures of the LES without peristalsis and lack of liquid transition from the esophagus into the stomach. It was then decided to proceed with a POEM procedure. APC was used to mark the site of dissection at 37 cm between 2 - 6 o'clock position. Normal saline mixed with methylene blue was injected to raise the mucosal layer, which was dissected with a 1.5 dual knife at the 5 o'clock position. Keeping the plane of the dissection in perspective the triangular tip (TT) knife was used to dissect the submucosal layer. Once the submucosal plane was dissected at the level of 37 cm, a submucosal tunnel was created along the line of the esophagus towards the distal esophagus into the lesser curvature. The submucosal tunnel was created up to 50 cm with the GEJ located 48 cm. Upon completion of the submucosal dissection the scope was brought back to the lumen of the esophagus and positioned at 37 cm in the submucosal window. Linear myotomy involving the circular muscle layer was performed followed by myotomy of the longitudinal muscle from 37 cm up to 50 cm. The scope was pulled back into the esophageal lumen and advanced down to the GEJ with smooth passage of the scope into the stomach without any resistance suggestive of successful myotomy. Five quick clips II were used to close the submucosal dissection site at 37 cm. On follow up the patient reports the ability to eat all types of food, no longer has dysphagia, coughing, or regurgitation, and states he feels back to his baseline. Robert frost once said, “A poem begins with a lump in the throat”. Little did he know he would correctly connect two important medical concepts years before their individual conception. This patient was successfully treated with this novel procedure, and we plan to further investigate the role of POEM in the treatment of achalasia on an ongoing basis.