S1864 Cricopharyngeal Per Oral Myotomy (C-POEM) for Treatment of a Cricopharyngeal Bar: A Novel Technique

Abstract

INTRODUCTION: Primary cricopharyngeal achalasia is a rare functional pathology and sub-type of traditional achalasia. While the exact etiology is unknown, it is characterized by a lack of pharyngeal contraction, improper coordination between the pharynx and upper esophageal sphincter (UES) or the inability of the UES to relax. The majority of the UES is made up of the cricopharyngeal muscle. Traditional treatment modalities include pneumatic dilatation, Botox injection and surgical myotomy. Cricopharyngeal per oral myotomy (C-POEM) can be an effective alternative minimally invasive procedure for patients before opting for more invasive surgical procedures. CASE DESCRIPTION/METHODS: A 76-year-old female presented with dysphagia for both liquid and solids. She was found to have cricopharyngeal achalasia on esophageal manometry. Past medical/surgical history included hypertension, hysterectomy and cholecystectomy. Pre-procedure esophagram visualized a non-relaxing cricopharyngeus muscle and was recommended to undergo C-POEM. A submucosal injection of ORISE lifting gel was used to elevate the mucosa to provide cushion for entry at the site of the initial dissection. The initial mucosal incision was made transversely using a Hybrid Knife I-Type. Then submucosal tunneling began through dissection of submucosal fibrous and connective tissues. The submucosal dissection was used to identify the cricopharyngeal bar. Once, submucosal tunneling was complete. circular myotomy of the cricopharyngeal muscle was performed along the longitudinal axis of the submucosal tunneling. Bleeding was minimal throughout the procedure and cautery was used effectively for hemostasis. The defect was closed using 3 endoscopic clips. Follow up endoscopy did show a healed scar from the tunnel entry. The upper esophageal sphincter was inspected with no cricopharyngeal bar re-occurrence. The patient's cricopharyngeal bar dysphagia was completely resolved. DISCUSSION: We have demonstrated the safety and efficacy of the POEM procedure in patients with cricopharyngeal bar. Along with more traditional therapeutic options, the C-POEM should be considered a viable alternative in patients suffering from cricopharyngeal bar.Figure 1.: Pre-POEM esophagram displaying a non-relaxing cricopharyngeus muscle.Figure 2.: Continued submucosal dissection to the cricopharyngeus muscle layer.Figure 3.: Myotomy of the cricopharyngeal muscle layer.