Yulia Zak, MD, Ozanan R Meireles, MD, David W Rattner, MD. Massachusetts General Hospital
OBJECTIVES: Peroral endoscopic myotomy (POEM) has been shown to be a new effective minimally invasive laparoendoscopic approach to achalasia. However, long-term outcomes of this procedure are yet to be determined. This is a case of a 74-year-old woman who underwent a POEM with complete resolution of dysphagia, but presented three months later with increasing gastroesophageal reflux that proved to be refractory to PPI therapy. Barium swallow demonstrated the presence of moderate spontaneous reflux above the level of the aortic arch, so laparoscopic Toupet fundoplication was recommended to the patient.
METHODS: Laparoscopic exploration revealed no adhesions or scarring in the region of the laparoendoscopic myotomy, and it was very difficult to distinguish the site of the prior muscle division. Intraoperative upper GI endoscopy showed no evidence of esophagitis but a widely patent gastroesophageal junction. The gastrohepatic and phrenoesophageal ligaments were opened and the esophagus was mobilized carefully, with minimal dissection along the anterior surface (site of the prior myotomy), and identification of both vagus nerves. The Toupet fundoplication was then constructed in a standard fashion, using three rows of 2-0 silk sutures, as well as a pexy of the posterior fundus to the crura. At the completion of fundoplication, there was no evidence of tension. Repeat upper endoscopy showed no obstruction to passage of the endoscope at the GE junction, with a new posterior anti-reflux valve clearly seen around the lower esophageal sphincter.
RESULTS: The patient recovered well after the procedure and has experienced complete resolution of her reflux symptoms.
CONCLUSIONS: Although POEM is a successful intervention for achalasia, its long-term complications include gastroesophageal reflux that may not be amenable to acid reducing medical therapy. In these patients, partial laparoscopic fundoplication is effective in managing these symptoms.