Sp707 How to Successfully Manage Novel Technical Challenges in Per Oral Endoscopic Myotomy for Achalasia

Abstract

Achalasia is a primary esophageal motility disorder and surgical disruption of the lower esophageal sphincter is usually performed, when conservative approaches failed to be sufficient. Since the first report of laparoscopic Heller myotomy in 1991, minimally invasive techniques have been increasingly used for definitive treatment of achalasia. Efforts in natural orifice translumenal surgery (NOTES) led to the development of novel methods such as submucosal endoscopic myotomy in an animal model. Recently, the clinical implementation of per oral endoscopic myotomy (POEM) was demonstrated. The clinical implementation of such novel procedures might conceal a novel variety of challenges, which have not been dealt with before. We describe the successful management of unexpected difficulties as well as lessons learned in an early clinical series of per oral endoscopic myotomies for the treatment of achalasia. We studied the initial five patients, enrolled in an institutional review board approved trial, who had per oral endoscopic myotomy for symptomatic achalasia. A conventional flexible endoscope with a transparent cap mounted onto the distal end was used. After mucosal incision and entry into the submucosal space, a tunnel within the esophageal wall was created using a blunt dissection or hook needle-knife cautery. The inner circular muscle fibers at the lower esophageal sphincter were then divided at a length of approximately 7 cm. The mucosal incision was then closed using hemostatic clips. All interventions were videotaped and analyzed on unexpected technical difficulties as well as their management were analyzed. POEM could be successfully performed in all patients (5/5) and resulted in immediate smooth passage of the endoscope through the gastro-esophageal sphincter. Although no clinical complications were observed, novel intra-operative technical challenges were observed. The transparent cap used on the endoscope loosened three times during retrograde movements and was subsequently lost within the submucosal tunnel. Several attempts to remove the submucosal foreign body with graspers or an endoscopic net failed as the cap twisted and was caught underneath the mucosa. With the aid of a balloon catheter the lost cap was finally lined-up with the endoscope and could be safely removed without injuring the esophageal mucosa. POEM appears to be an appealing therapeutic approach for achalasia and the knowledge of basic rescue maneuvers in case of technical challenges might be essential to shorten the learning curve of endoscopists and ensure patient's safety.