Matthew L Dong, MD, MPH, Matthew Davis, MD, Amit Bhatt, MD, Jeffrey Ponsky, MD, Matthew Kroh, MD. Cleveland Clinic
Achalasia is an esophageal dysmotility disorder, affecting approximately 1 in 100,000 people, and is characterized by inadequate or impaired relaxation of the lower esophageal sphincter, with absent or disordered peristalsis of the esophagus. It can result in debilitating dysphagia, odynophagia, regurgitation, and in severe cases, weight loss and malnutrition. Medical therapy, consisting of calcium channel blockers and nitrates, can provide some symptomatic relief in early or mild achalasia or in patients with contraindications to endoscopic or surgical intervention. Endoscopic balloon dilation of the LES is often effective, but the resultant scarring can make future surgical interventions more difficult and carries an approximately 4% perforation rate. Endoscopic injection of botulinum toxin can provide some mechanical relief, but the effects are transient, generally lasting 3-6 months. Surgical options for achalasia include open or laparoscopic Heller myotomy. More recently, per oral endoscopic myotomy (POEM) has begun to gain traction at select centers. Early results show that in capable hands, POEM is an effective and safe therapy for achalasia, with the advantage of shorter hospital stay and no incisions, but the rate of complications, and the management thereof, is not well described. The purpose of this study is to provide useful techniques for managing intra-operative and post-operative complications arising from POEM.
Methods and Procedures
We describe the management of three patients who underwent POEM, who each had a different complication, one intraoperative and two postoperative.
Our first patient had an inadvertent second mucosotomy, at the distal end of the submucosal tract. This was recognized at the time of its creation. The mucosotomy was closed with a series of endoscopic clips. Following this, intraoperative fluoroscopy showed no leakage of contrast. A routine post-operative upper GI series also demonstrated no leak. The patient had an uneventful post-operative recovery.
The second patient had findings of incomplete closure of his mucosotomy and a persistent submucosal tract on postoperative upper GI series. He was initially managed with total parenteral nutrition but was readmitted with dysphagia and upper abdominal and chest pain. He was treated endoscopically, with two overlapping fully covered esophageal stents, which were left in place for one week. Follow up studies showed closure of this tract.
The third patient had an uneventful POEM and recovery but was readmitted on postoperative day 10 with an upper gastrointestinal bleed. This was initially low volume but became significant shortly after his arrival. Endoscopy showed no active bleeding at the time of the procedure and a partially covered esophageal stent was placed. This was removed after three days and repeat endoscopy showed no evidence of continued bleeding and an intact mucosotomy closure site.
POEM is a novel procedure for incision-less surgical management of achalasia. Early results are encouraging that it is safe and effective, but due to small case numbers, descriptions of techniques for management of post-operative and intra-operative complications are few. Both endoscopic stenting and clipping are useful tools and should be considered in troubleshooting pathways although their specific applications have yet to be determined.