Repeat peroral endoscopic myotomy with simultaneous submucosal and muscle dissection as a salvage option for recurrent achalasia

Figure 1 Repeat peroral endoscopic myotomy with simultaneous submucosal and muscle dissection in a 28-year-old woman with recurrence of symptoms after previous peroral endoscopic myotomy. A: Radiographic image showing the difficulty of barium to pass through the pipe into the stomach; B: The mucosal scar of previous peroral endoscopic myotomy; C: Reverse T incision of submucosal entry near the scarred area; D: Construction of the submucosal tunnel; E: Obvious submucosal fibrosis disconnected by electrocoagulation forceps; F: Simultaneous submucosal and muscle dissection started from the muscular scar; G: Full-thickness myotomy of the esophagus; H: Exact hemostasis using hemostatic forceps; I: Closure of the mucosal entry point with metal clips.

Figure 2 Eckardt score changes in patients with recurrent achalasia. POEM: Peroral endoscopic myotomy; Re-POEM: Repeat peroral endoscopic myotomy; Re-POEM-SSMD: Repeat peroral endoscopic myotomy with simultaneous submucosal and muscle dissection.

Figure 3 Lower esophageal sphincter pressure changes in patients with recurrent achalasia. Re-POEM: Repeat peroral endoscopic myotomy; Re-POEM-SSMD: Repeat peroral endoscopic myotomy with simultaneous submucosal and muscle dissection.