Update on the endoscopic treatments for achalasia

Figure 4 Per oral endoscopic myotomy in a patient with achalasia. A 56-year-old man with type II achalasia and a history of chronic alcohol use underwent attempted laparoscopic Heller myotomy. Upon retraction of the liver during surgery, large gastroesophageal varices were noted to arise and the surgery was aborted. The patient was exhorted to stop drinking alcohol. Doppler ultrasonography and magnetic resonance imaging with arterial and venous phase imaging did not show any significant gastroesophageal varices or obvious portal hypertension. Per oral endoscopic myotomy (POEM) was performed. Endoscopic views in the distal esophagus found some enlarged veins but no high-grade esophageal or gastric varices (A); Radial endosonography found a thickened deep circular muscle layer measuring 2.9 mm, which is commonly found in patients with achalasia, but no obvious esophageal varices were noted (B); A mucosal weal was created by injecting saline tinted with indigo carmine (C); and a mucosal entry incision was made (D); Submucosal dissection was carried out with sequential injection and electrosurgical dissection (E) using a T-type Hybrid knife in conjunction with an ERBEJET 2 and a VIO 300 D generator set at EndoCut Q 3-2-1 (ERBE, Marietta, GA, United States). Dissection of the circular layer of the muscularis propria was performed using the T-type Hybrid knife (F); After completion of the 7-cm-long myotomy in the distal esophagus that was carried out an additional 2 cm into the gastric cardia (G); the mucosal entry site was closed by using endoclips (H). The patient did well without any intra- or post-procedural bleeding. At clinic follow-up 2 mo later, the patient reported complete resolution of his symptoms of dysphagia and weight gain of 14 lbs.