Case Report
Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Endosc. Oct 16, 2016; 8(18): 669-673
Published online Oct 16, 2016. doi: 10.4253/wjge.v8.i18.669
Same site submucosal tunneling for a repeat per oral endoscopic myotomy: A safe and feasible option
Antonios N Wehbeh, Parit Mekaroonkamol, Qiang Cai
Antonios N Wehbeh, Department of Internal Medicine, Emory University School of Medicine, Atlanta, GA 30322, United States
Parit Mekaroonkamol, Qiang Cai, Department of Internal Medicine, Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA 30322, United States
Author contributions: Wehbeh AN and Mekaroonkamol P conducted the literature review; Wehbeh AN, Mekaroonkamol P and Cai Q drafted and edited the manuscript, and approved the final version submitted; Cai Q captured the images and is the guarantor of the article.
Institutional review board statement: We submitted a review request to our IRB but based on our institutional policy, a case report of less than 6 patients does not require an IRB review.
Informed consent statement: Patient gave informed consent prior to getting the procedure done.
Conflict-of-interest statement: The authors declare no conflict of interest.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Correspondence to: Qiang Cai, MD, PhD, Professor of Medicine, Director of Advanced Endoscopy Fellowship, Department of Internal Medicine, Division of Digestive Diseases, Emory University School of Medicine, 1365 Clifton Road, B1262, Atlanta, GA 30322, United States.
Telephone: +1-404-7782714 Fax: +1-404-7782578
Received: May 13, 2016
Peer-review started: May 16, 2016
First decision: July 4, 2016
Revised: July 11, 2016
Accepted: July 29, 2016
Article in press: August 1, 2016
Published online: October 16, 2016

Per oral endoscopic myotomy (POEM) is a novel endoscopic procedure for achalasia treatment. Due to its novelty and high success rates, a repeat procedure is usually not warranted, making the feasibility and safety of such approach unknown. We report the first case of a successful repeat POEM done at the same site of a previously uncompleted POEM. An 84-year-old female with type 2 achalasia presented for a POEM procedure. The procedure was aborted at the end of tunneling and before myotomy due to hypotension, which later resolved spontaneously. POEM was re-attempted at the same site of the original tunnel 1 year afterward, and surprisingly we didn’t encounter any submucosal fibrosis. The procedure felt similar to a native POEM and a myotomy was performed uneventfully. Our case is the first to suggest that submucosal tunneling during a repeat POEM can be done at the same site. Hypotension during POEM is a rare complication that should be recognized as a potential result of tension capnothorax, it can however, be managed with close supportive care.

Keywords: Per oral endoscopic myotomy, Achalasia, Myotomy, Submucosal tunnel, Repeat procedure, Submucosal fibrosis

Core tip: Per oral endoscopic myotomy (POEM) is a novel method of treating achalasia. More is being learnt about potential complications as it increases in popularity. This is the first case of a repeat submucosal tunneling done at the same site of a prior POEM attempt which was aborted just before myotomy. No complications or difficulties were encountered during the second attempt. This may suggest that submucosal tunneling does not cause fibrosis, and that repeat POEM after a technically unsuccessful attempt could be done at the same site and orientation of the original tunnel.