Nutcracker Esophagus: Post-POEM Thorascopic Rescue of Persistent Dysphagia

Ran B Luo, MD, Shanglei Liu, MD, Jonathan C DeLong, MD, Alisa M Coker, MD, Caitlin Houghton, MD, Bryan J Sandler, MD, FACS, Garth R Jacobsen, MD, FACS, Santiago Horgan, MD, FACS. University of California, San Diego

This video demonstrates both a Peroral Endoscopic Myotomy (POEM) and a subsequent thorascopic esophagomyotomy for nutcracker esophageal disease. The patient is a 48 year old woman who had progressive dysphagia and chest pain for the past few years. Endoscopic procedures such as botox and balloon dilation had proven unsuccessful at treating her symptoms. She was then offered a POEM procedure as a minimally invasive way to treat her pathology. Despite an uncomplicated course and improvement of her dysphagia, her chest pain persisted. A thorascopic esophagomyotomy was then performed extending 15cm down from the azygous vein. The key steps of the POEM procedure, including submucosal tunneling, cautery resection of the circular muscles through the esophago-gastric junction, and clip closure of the mucosotomy are shown and described. The key steps of the thorascopic esophagomyotomy, including port placement, identification of the azygous vein, the extended myotomy, pre and postoperative manometry and endoscopy are all shown and described. 

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