Successful Peroral Endoscopic Myotomy for Long-Standing Dysphagia Due to Achalasia Cardia
PACE Hospitals
PACE Hospitals’ Gastroenterology team successfully performed a Peroral Endoscopic Myotomy (POEM) on a 44-year-old male patient diagnosed with Achalasia Cardia Type II (Eckardt Score – 4), with the aim of relieving lower oesophageal sphincter obstruction, improving swallowing, and restoring normal food intake without the need for open surgery.
Chief Complaints
A 44-year-old male patient with a body mass index (BMI) of 17 presented to the Gastroenterology Department at PACE Hospitals, Hitech City, Hyderabad, with complaints of progressive difficulty in swallowing both liquids and solids for the past 10 years. The symptoms were occasionally associated with vomiting and significantly affected his ability to eat comfortably.
Past Medical History
The patient had no documented history of significant medical comorbidities such as diabetes mellitus, hypertension, heart disease, chronic kidney disease, or respiratory illness. There was no reported history of previous major surgeries or hospital admissions. No known drug, food, or other allergies were documented at the time of admission.
On Examination
On examination, the patient was conscious, coherent, oriented, and hemodynamically stable. General physical examination showed no signs of acute distress, dehydration, pallor, jaundice, or peripheral oedema. Abdominal examination revealed a soft, non-tender, and non-distended abdomen, with no palpable masses or organ enlargement. Cardiovascular and respiratory examinations were normal, and the remaining systemic examination was within normal limits.
Diagnosis
Upon admission to PACE Hospitals, following a detailed clinical assessment, the Gastroenterology team evaluated the patient for long-standing difficulty in swallowing both liquids and solids, occasionally associated with vomiting, along with a review of his relevant medical history and previously performed investigations.
Upper gastrointestinal endoscopy and oesophageal manometry findings were reviewed and were consistent with Achalasia Cardia Type II with an Eckardt score of 4. The diagnosis was established based on the characteristic history of progressive dysphagia, associated symptoms, and objective evidence of impaired lower oesophageal sphincter relaxation and abnormal oesophageal motility.
Routine investigations, including complete blood picture, serum electrolytes, renal function tests, cardiac evaluation, and pre-anaesthetic assessment, were performed as part of the pre-procedural evaluation to assess the patient’s overall medical fitness. These investigations were within acceptable limits and served as supportive assessments before the planned intervention.
Based on the confirmed diagnosis, the patient was advised to undergo Achalasia Cardia Type II Treatment in Hyderabad, India, under the expert care of the Gastroenterology and Therapeutic Endoscopy team at PACE Hospitals.
Medical Decision Making (MDM)
After a detailed consultation with Dr. Govind Verma (Interventional Gastroenterologist and Hepatologist) and Consultant Gastroenterologist Dr. M. Sudhir, a comprehensive evaluation was performed to determine the most appropriate therapeutic approach.
Considering the patient’s 10-year history of difficulty in swallowing both liquids and solids, occasionally associated with vomiting, and the findings of upper gastrointestinal endoscopy and oesophageal manometry, the diagnosis of Achalasia Cardia Type II with an Eckardt score of 4 was confirmed. Routine laboratory investigations, cardiac fitness assessment, and pre-anaesthetic evaluation showed acceptable parameters for the planned intervention.
Based on the clinical assessment and diagnostic findings, it was determined that Peroral Endoscopic Myotomy (POEM) under general anaesthesia was the most appropriate and effective treatment strategy. This minimally invasive endoscopic procedure was selected to divide the abnormally tight lower oesophageal sphincter muscles, reduce functional obstruction, improve the passage of food and liquids into the stomach, and provide sustained relief from dysphagia without the need for external surgical incisions.
The patient and his family members were counselled regarding the diagnosis, planned POEM procedure, potential benefits and risks, expected dietary progression, postoperative monitoring, and the importance of regular follow-up.
Surgical Procedure
Following the decision, the patient was scheduled for Peroral Endoscopic Myotomy (POEM) in Hyderabad at PACE Hospitals, under the expert care of the Gastroenterology Department.
The following steps were carried out during the procedure:
- Patient Preparation and Anaesthesia: After completing the required investigations, cardiac fitness assessment, pre-anaesthetic evaluation, and informed consent, the patient was administered intravenous antibiotics. General anaesthesia was given, and the patient was positioned appropriately for the endoscopic procedure.
- Endoscopic Entry and Mucosal Incision: A flexible upper gastrointestinal endoscope was passed through the mouth into the oesophagus. A small mucosal incision was created in the oesophageal wall to provide access to the submucosal space.
- Creation of the Submucosal Tunnel: A submucosal tunnel was carefully developed along the oesophageal wall and extended across the gastro-oesophageal junction into the upper part of the stomach. This created a safe working space for the myotomy.
- Oesophageal Myotomy: The tight circular muscle fibres of the lower oesophagus and lower oesophageal sphincter were selectively divided. This reduced the functional obstruction and allowed food and liquids to pass more easily into the stomach.
- Closure and Completion: After confirming adequate myotomy and ensuring there was no active bleeding or visible injury, the mucosal entry site was securely closed with endoscopic clips. The procedure was completed successfully without complications.
Postoperative Care
Following the POEM procedure, the patient was kept nil by mouth for two days and monitored closely for pain, fever, bleeding, breathing difficulty, or signs of oesophageal leakage. Intravenous fluids were given to maintain hydration, along with supportive treatment for infection prevention, fungal infection prevention, pain control, nausea and vomiting control, and gastric acid suppression. An oral Gastrografin study was performed to confirm smooth passage across the gastro-oesophageal junction and to rule out any leakage or significant retention. After satisfactory findings, the patient was gradually started on a liquid diet and monitored for improvement in swallowing before discharge.
Discharge Medications
Upon discharge, the patient was prescribed oral medications to prevent infection, reduce gastric acid exposure and protect the healing oesophageal lining, control pain and discomfort when required, relieve nausea or vomiting, and support smooth recovery.
Advice on Discharge
The patient was advised to follow a liquid diet for four days, then a semi-solid diet for four days, and gradually resume a normal diet. Adequate hydration, regular medications, and follow-up were advised.
Emergency Care
The patient was informed to contact the emergency ward at PACE Hospitals in case of any emergency or development of symptoms such as fever, severe chest or abdominal pain, persistent vomiting, difficulty in swallowing, breathing difficulty, or blood in vomiting.
Review and Follow-up Notes
The patient was advised to return for a follow-up visit with the Gastroenterologist in Hyderabad at PACE Hospitals after 30 days.
Conclusion
This case highlights the successful management of Achalasia Cardia Type II using Peroral Endoscopic Myotomy. The procedure effectively relieved the lower oesophageal sphincter obstruction, improved swallowing, and enabled the patient to resume oral intake comfortably without complications.
Importance of Timely POEM Treatment in Achalasia Cardia
Achalasia Cardia is a progressive oesophageal motility disorder that can gradually affect swallowing, nutrition, and quality of life. In this case, the patient experienced difficulty swallowing liquids and solids for nearly 10 years before receiving definitive treatment. POEM provided a minimally invasive approach to relieve the tight lower oesophageal sphincter without external surgical incisions. Accurate diagnosis by a gastroenterologist / gastroenterology doctor through endoscopy and oesophageal manometry was essential for selecting the appropriate treatment. Post-procedure contrast evaluation confirmed smooth passage across the gastro-oesophageal junction without leakage. Timely intervention, structured dietary progression, and regular follow-up can help achieve sustained symptom relief and improve long-term swallowing function.
Frequently Asked Questions (FAQs)
Who may be advised to undergo a POEM procedure?
POEM may be recommended for people with confirmed achalasia who continue to have difficulty swallowing because the lower end of the oesophagus does not relax properly. Before suggesting the procedure, the doctor usually reviews the patient’s symptoms, endoscopy findings, and oesophageal manometry results. It can be considered for different types of achalasia, depending on the individual case.
Why was POEM preferred over conventional surgery in this case?
POEM was selected because it could relieve the tight lower oesophageal sphincter without making an external surgical incision. The procedure is performed through the mouth using an endoscope, which generally means less postoperative discomfort and a quicker recovery. The final choice of treatment depends on the type of achalasia, test results, and the specialist’s assessment.
What tests are usually required before POEM?
Before POEM, the doctor reviews the patient carefully to confirm the diagnosis and plan the procedure. Upper gastrointestinal endoscopy and oesophageal manometry are commonly done to assess how the oesophagus and lower oesophageal sphincter are functioning. In some cases, a contrast study may also be advised. Blood tests, heart evaluation, and a pre-anaesthetic check-up are completed to confirm that the patient is fit to undergo the procedure.
Is POEM considered a major surgery?
POEM is not an open surgical procedure, but it is still a specialised therapeutic intervention. It is performed under anaesthesia using an endoscope passed through the mouth. Since the procedure involves cutting selected muscle fibres of the oesophagus, it should be carried out by an experienced therapeutic endoscopist in a well-equipped hospital.
How long does recovery take after POEM?
Recovery after POEM is usually faster than after conventional surgery. Patients are monitored in the hospital and are started on oral intake only after the doctor confirms that there is no leak. Diet is gradually advanced from liquids to semi-solid foods and then to regular food, depending on the patient’s recovery and medical advice.
Why is a Gastrografin test done after POEM?
The Gastrografin swallow test is done after POEM to make sure the passage from the oesophagus into the stomach is clear and that there is no leak. It also helps the doctor decide when it is safe to restart oral intake. In this case, the contrast passed smoothly without any blockage, retention, or leakage.
How soon can swallowing improve after POEM?
Many patients begin to feel some relief in swallowing within the first few days after POEM. In others, the improvement may be more gradual as the treated area heals. Temporary soreness or swelling can make swallowing uncomfortable at first, but this usually settles with time. Food and liquids generally become easier to take as recovery progresses.
Can swallowing problems return after POEM?
POEM provides long-term relief for many people with achalasia, but symptoms may return in a small number of patients. Achalasia is a long-term motility disorder, so follow-up remains important even after a successful procedure. Any renewed difficulty in swallowing, regurgitation, or chest discomfort should be discussed with a gastroenterologist.
What diet should be followed after POEM?
After POEM, patients are usually advised to begin with a liquid diet, followed by semi-solid food, before gradually returning to a normal diet. Food should be eaten slowly and chewed thoroughly. Adequate hydration and strict adherence to the dietary plan help protect the healing area and reduce discomfort.
Why is follow-up necessary after a successful POEM procedure?
Even after a successful POEM procedure, follow-up is important to see how well the patient is swallowing and tolerating food. It also gives the doctor a chance to check for reflux, persistent discomfort, or any return of swallowing difficulty. Further tests or treatment can then be planned only if needed.
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