Successful POEM Procedure Restored Swallowing in a 72 Y.O. Female with Type 2 Achalasia Cardia

A 72-year-old female patient with a body mass index (BMI) of 19 presented to the Gastroenterology Department at PACE Hospitals, Hitech City, Hyderabad, with a one-month history of difficulty swallowing both liquids and solids, accompanied by a sensation of food getting stuck in the throat.

The patient had no known history of hypertension or diabetes. The absence of these comorbid conditions was considered clinically favourable, as it minimised the risk of intraoperative and postoperative complications and supported a smoother, more stable recovery.

On examination, the patient was conscious, coherent, oriented, and in stable general condition. Vital signs were normal. Abdominal examination revealed a soft, non-tender abdomen with no organomegaly. Cardiovascular, respiratory, and other systemic examinations were normal. Overall, the patient’s condition on examination was stable.

Upon admission to PACE Hospitals, the patient was thoroughly evaluated by the Gastroenterology team, presenting with a one-month history of progressive difficulty in swallowing both liquids and solids, accompanied by a sensation of food getting stuck. There was a strong clinical suspicion of achalasia cardia, a primary esophageal motility disorder.

A comprehensive diagnostic workup was performed. Esophageal manometry confirmed Type II Achalasia, demonstrating high lower esophageal sphincter (LES) pressure with incomplete LES relaxation and panesophageal pressurization, and also revealed a hiatus hernia. Upper gastrointestinal (UGI) endoscopy showed moderate resistance at the gastroesophageal junction (GEJ) and erosive gastroduodenitis, consistent with achalasia cardia. Laboratory investigations—including complete blood picture, renal function tests, liver function tests, electrolytes, thyroid profile, and lipid profile—were within normal limits, except for mild eosinophilia noted on peripheral smear. Chest X-rays were unremarkable.

Based on the confirmed diagnosis, the patient was advised to undergo Achalasia Cardia Treatment in Hyderabad, India, under the expert care of the Gastroenterology Department.

After a detailed consultation with the consultant gastroenterologists, Dr. Govind Verma, Dr. Padma Priya, Dr. M Sudhir, and Dr Arun Kumar Palakurthi, along with cross-consultation from Dr. Suresh Kumar S, Surgical Gastroenterologist, a thorough evaluation was conducted considering the patient’s complaints of progressive difficulty in swallowing both liquids and solids over one month, associated with a sensation of food getting stuck. All relevant clinical findings were reviewed.

Based on this comprehensive assessment, it was determined that Peroral Endoscopic Myotomy (POEM) was identified as the most appropriate intervention to relieve obstruction at the lower esophageal sphincter, improve swallowing, and prevent further esophageal complications. The surgical gastroenterology team provided cross-consultation to ensure procedural feasibility and safety.

The patient and her family members were counselled regarding the diagnosis, the procedure, associated risks, post-procedure dietary and lifestyle modifications, and the expected symptomatic improvement following the intervention.

Following the decision, the patient was scheduled for Peroral Endoscopic Myotomy (POEM) Surgery in Hyderabad at PACE Hospitals, under the expert care of the Gastroenterology Department.

The Peroral Endoscopic Myotomy (POEM) procedure was carried out in the following steps:

• Preparation and Anesthesia: The patient was given intravenous antibiotics and placed under short general anesthesia for the procedure. CO₂ insufflation was used throughout to maintain adequate visualization during endoscopy.

• Mucosal Incision: Using an endoscope, the mucosa was infiltrated with a submucosal injection solution approximately 10 cm above the gastroesophageal (GE) junction at the 6 o’clock position. A small mucosal incision was then made with a T-type electrosurgical knife.

• Submucosal Tunneling: A submucosal tunnel was created between the mucosal and muscular layers, with coagulation of vessels using a coagulation grasper to prevent bleeding, extending across the Lower Esophageal Sphincter (LES) into the proximal stomach.

• Muscle Myotomy: Circular muscle fibers of the distal esophagus and LES were carefully cut using a hybrid knife over a length of 10–12 cm to relieve obstruction caused by achalasia.

• Closure and Final Check: The mucosal incision was closed using Medorah endoscopic clips. The endoscope was then passed through the GE junction to confirm free passage and ensure no complications.

The procedure was completed successfully without any complications, and the patient was monitored closely for a stable recovery.

The postoperative recovery was uneventful. On post-op day 2, an oral gastrograffin study confirmed normal passage of contrast across the gastroesophageal junction without retention, dilatation, or extravasation. During the hospital stay, the patient received supportive care for hydration, infection prevention, and symptom relief, with close monitoring for potential complications such as bleeding or swallowing difficulties.

Gradual oral intake was initiated once tolerance was confirmed, and the patient was advised on proper meal consistency and eating habits to minimize discomfort. The patient showed progressive symptomatic improvement, remained stable, and was discharged with instructions for follow-up.

Upon discharge, the patient was advised to continue medications for bone and vitamin support, infection prevention, acid suppression, gut motility support, antifungal therapy, pain relief, and digestive support.

The patient was advised to consume lukewarm water before and after each meal and to sit in an upright position for 30 minutes following meals. They were instructed to take small, frequent meals and to chew food properly. Additionally, they were advised to use incentive spirometry as part of their recovery routine.

The patient was advised to follow a warm liquid diet for 2 days, followed by a semisolid diet for 3 weeks. They were instructed to avoid cold drinks or cool water, maida, dhokla, biscuits, bread, and chilly or spicy foods.

The patient was informed to contact the emergency ward at PACE hospitals in case of emergency or having any symptoms like fever, vomiting and abdominal pain.

The patient was advised to return for a follow-up visit with the Gastroenterologist in Hyderabad at PACE Hospitals  after one month.

This case highlights the successful treatment of achalasia cardia type 2 using peroral endoscopic myotomy (POEM). The procedure was completed uneventfully with precise myotomy and secure closure. Postoperative evaluation showed normal passage across the gastroesophageal junction without complications. The patient improved symptomatically and was stable at discharge.