Thursday, January 9, 2014

Per Oral Endoscopic Myotomy for Achalasia cardia: Tunnelling the esophagus. 
With the advent of NOTES (Natural Orifice Transluminal Endoscopic Surgery) there has been a recent addition of an incisionless surgery called Per Oral Endoscopic Myotomy (POEM) in the treatment armamentarium of achalasia cardia.

We report a 52 years female otherwise healthy but symptomatic for progressive dysphagia since 12 years. For the past six months she had worsening of symptoms associated with vomiting, nasal and oral regurgitation and weight loss of 16 kgs. She was diagnosed as Achalasia cardia based on endoscopic, barium and high resolution manometric findings. Prior to the procedure resting LES pressure on HRM was 69.8 mmHg. Her Eckardt dysphagia score was 9/12.  She underwent pneumatic balloon dilation once without any symptom relief. She was then offered laparoscopic Heller’s myotomy and POEM. She opted for POEM. 

She underwent POEM under general anaesthesia.  We used a high definition endoscope (Olympus GIF H180) and transparent cap (Olympus MH 588).  An incision was made in the mucosa 15cms above the GE junction using a hybrid knife ( electrogenerator, Erbe Vio 300D; Erbe Elektromedizin, Germany)   . This mucosal incision was made after submucosal instillation of saline along the right anterolateral esophageal wall. The endoscope was then inserted into the submucosa at the site of incision and a submucosal tunnel was created from the incision till 1 cm beyond GE Junction. Spray coagulation mode was used to dissect the submucosa. Continuous infiltration of a solution made of 100ml saline mixed with indigocarmine and 1 ml adrenaline was done to separate the mucosa and to detect any small mucosal tear. A coagulating forceps (FD-410LR Coagrasper; Olympus) was used for hemostasis as needed. The time required for creating the tunnel was 53 mins. The GE junction was identified by palisade vascular pattern and premeasured distance from the incisors. The endoscope was then withdrawn from the tunnel and introduced in the esophagus to look for any mucosal break.  The endoscope was re-inserted in the tunnel and muscle cutting was started 4 cms below the mucosal incision. Circular as wells as longitudinal muscle of the esophagus were incised very gently in millimetres so as to avoid injury to the adjacent mediastinal structures. The muscle cutting was continued till the end of the tunnel. The total muscle cutting time was 25 mins. There was a tiny mucosal break which was closed with a standard endoscopic hemoclip. The mucosal incision was finally closed with six endoscopic clips (HX-110UR EZ Clip Reusable Rotatable Clip Fixing Device and HX-610-135L Single Use Clips; Olympus).

Since the time we reported first case of POEM from India so far we have performed 75 cases till date.

Dr. Amit Maydeo
Director, Baldota Institute of Digestive Sciences, Global Hospitals Mumbai
Dr. Nitin Joshi, BIDS.
Consultant Gastroenterologist
Dr. S P Bhandari, BIDS.
Consultant Endoscopic Surgeon
Dr. Mukta Bapat
Consultant Gastroenterologist, BIDS.
Dr. Vinay Dhir
Chief of Endosonography and Head Clinical Research, BIDS.

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