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Case Report

Challenges of peroral endoscopic myotomy in the treatment of distal esophageal spasm

ORCID Icon, , &
Pages 252-255 | Received 18 Aug 2017, Accepted 29 Dec 2017, Published online: 17 Jan 2018
 

Abstract

Objective: Distal esophageal spasm (DES) is a rare motility disorder characterized by premature and rapidly propagated contractions of the distal esophagus. Treatment options are limited and often poorly effective. Peroral endoscopic myotomy (POEM) seems an effective and attractive new treatment option for DES. In this case report we describe some of the difficulties that could arise.

Materials and methods: A 84-year old man with therapy-refractory DES and complaints of severe dysphagia and chest pain underwent a POEM procedure under general anesthesia. A longer myotomy was performed to cleave the circular muscle layer from start till end of the spastic contractions.

Results: The length of the myotomy was 16 cm. Hyperactive spastic contractions during the procedure complicated the creation of the submucosal tunnel, extended the duration (134 vs. 60–90 min for achalasia), increased postoperative pain and prolonged hospital admission. Intravenously nitroglycerin peroperative diminished spastic contractions. Postoperative a remnant of spastic contractions was present, proximal to the myotomy, causing persistent symptoms.

Conclusion: Performing POEM for DES is challenging due to reactive hyperactive spastic contractions during the procedure causing technical difficulties and an extended procedure. A long myotomy, several centimeters above the proximal border of the spastic region, is essential to prevent remnants of spasticity.

Disclosure statement

F.A. Ponds: No conflicts of interest.

A.J.P.M. Smout: Bayer (personal fee), Almirall (personal fee)and Will-Pharma (personal fee).

P. Fockens: Olympus (grant, personal fee), Fuijfilm (grant)and Cook (grant, personal fee), Boston (grant).

A.J. Bredenoord: Endostim (grant), Medical Measurement Systems (grant, personal fee), Danone (grant), GivenImaging (grant), Astellas (personal fee), AstraZeneca (personal fee) and Almirall (personal fee).