William D Gerull, BS, Jeffrey Blatnik, MD, Michael M Awad, MD, PhD. Washington University School of Medicine
The patient is a fifty-five year old female with a four year history of retrosternal pain while eating and dysphagia to solid foods at every meal. She denies any regurgitation or weight loss, and has an Eckardt score of 6. Repeated botulinum toxin injections provided transient relief of her symptoms for one year.
The barium swallow showed significant tortuosity and irregularity of the distal half of the esophagus, and two diverticula, one in the left anterolateral portion of the esophagus and the other in the right anterolateral portion, slightly more distal. The esophageal manometry showed normal lower esophageal sphincter function, low amplitude pressure compartmentalization in the distal esophagus, and disorganized contraction in the esophageal body with wave abnormalities consistent with a spastic motor disorder of the esophagus.
In order to avoid the two anterior diverticula and to create an extended posterior myotomy, a POEM procedure was felt to be most appropriate. Following creation of a submucosal tunnel, a posterior myotomy was performed starting 14 cm proximal to the LES and extended distally 2 cm onto the proximal stomach. Endoscopic clips were used to close the mucosotomy.
The patient’s post-operative course was uncomplicated and she was discharged on post-op day #1. The aqueous esophagram showed no leak and two small esophageal diverticular still present. The patient returned to clinic one month later and reported complete resolution of dysphagia, minimal residual chest pain, and no regurgitation or weight loss, producing an Eckardt score of 1.
In conclusion, POEM is a safe and effective option when an extended myotomy is needed for spastic motility disorders of the esophagus. POEM may be safer and more technically feasible than the laparoscopic approach when a posterior myotomy is required, as in this case where anterior esophageal diverticula are present.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 84834
Program Number: V278
Presentation Session: Friday Video Loop (Non CME)
Presentation Type: VideoLoop