VIDEOGIE Todd H. Baron, MD, G. S. Raju, MD, Editors for VideoGIE
Double peroral endoscopic myotomy for achalasia
Figure 1. Endoscopic image illustrating 2 esophageal mucosal incisions (anterior and posterior walls) during a case of double peroral endoscopic myotomy for achalasia.
As experience grows with peroral endoscopic myotomy (POEM), operators are taking on more anatomically challenging cases. Additionally, we are now seeing patients who relapse after a prior POEM. Therefore, the operator must be aware of the steps necessary to adequately investigate and treat such patients. For example, it is of no benefit to continue to target the lower esophageal sphincter if this already has been treated effectively. We herein present 2 different teaching cases in which 2 POEM procedures (double POEM) were performed in each of the patients (Video 1, available online at www. giejournal.org). The first case is a patient who was initially diagnosed with type II achalasia and underwent POEM. The patient did not respond adequately after 6 months, and repeat investigation revealed that the patient in fact had type III achalasia. He therefore required proximal extension of the myotomy. To avoid a new second POEM with a long myotomy on the posterior wall, the decision was made
This video can be viewed directly from the GIE website or by using the QR code and your mobile device. Download a free QR code scanner by searching “QR Scanner” in your mobile device’s app store. www.giejournal.org
to perform POEM such that the new myotomy would meet the previous one. The second patient was status post Heller myotomy with symptom relapse. She underwent a posterior POEM, but during submucosal tunneling, the prior surgical myotomy was identified. The decision was made to perform a new POEM on the anterior wall under the same anesthetic (Fig. 1). DISCLOSURE M. Khashab is a consultant for Boston Scientific, Xlumena, and Olympus America and has received research support from Cook Medical. P. Saxena is a consultant for Boston Scientific and has received consulting fees from Olympus Australia, Cook Medical, and Pentax Medical and received research support from Cook Medical. All other authors disclosed no financial relationships relevant to this article. Vivek Kumbhari, MD, Alan H. Tieu, MD, Alba Azola, MD, Payal Saxena, MD, Saowanee Ngamruengphong, MD, Mohamad H. El Zein, MD, Mouen A. Khashab, MD, Department of Medicine and Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA http://dx.doi.org/10.1016/j.gie.2015.05.036
Volume 82, No. 5 : 2015 GASTROINTESTINAL ENDOSCOPY 953
Double peroral endoscopic myotomy for achalasia
Figure 1. Endoscopic image illustrating 2 esophageal mucosal incisions (anterior and posterior walls) during a case of double peroral endoscopic myotomy for achalasia.
As experience grows with peroral endoscopic myotomy (POEM), operators are taking on more anatomically challenging cases. Additionally, we are now seeing patients who relapse after a prior POEM. Therefore, the operator must be aware of the steps necessary to adequately investigate and treat such patients. For example, it is of no benefit to continue to target the lower esophageal sphincter if this already has been treated effectively. We herein present 2 different teaching cases in which 2 POEM procedures (double POEM) were performed in each of the patients (Video 1, available online at www. giejournal.org). The first case is a patient who was initially diagnosed with type II achalasia and underwent POEM. The patient did not respond adequately after 6 months, and repeat investigation revealed that the patient in fact had type III achalasia. He therefore required proximal extension of the myotomy. To avoid a new second POEM with a long myotomy on the posterior wall, the decision was made
This video can be viewed directly from the GIE website or by using the QR code and your mobile device. Download a free QR code scanner by searching “QR Scanner” in your mobile device’s app store. www.giejournal.org
to perform POEM such that the new myotomy would meet the previous one. The second patient was status post Heller myotomy with symptom relapse. She underwent a posterior POEM, but during submucosal tunneling, the prior surgical myotomy was identified. The decision was made to perform a new POEM on the anterior wall under the same anesthetic (Fig. 1). DISCLOSURE M. Khashab is a consultant for Boston Scientific, Xlumena, and Olympus America and has received research support from Cook Medical. P. Saxena is a consultant for Boston Scientific and has received consulting fees from Olympus Australia, Cook Medical, and Pentax Medical and received research support from Cook Medical. All other authors disclosed no financial relationships relevant to this article. Vivek Kumbhari, MD, Alan H. Tieu, MD, Alba Azola, MD, Payal Saxena, MD, Saowanee Ngamruengphong, MD, Mohamad H. El Zein, MD, Mouen A. Khashab, MD, Department of Medicine and Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA http://dx.doi.org/10.1016/j.gie.2015.05.036
Volume 82, No. 5 : 2015 GASTROINTESTINAL ENDOSCOPY 953
