Successful Peroral Endoscopic Myotomy (POEM) for Type II Achalasia Cardia
PACE Hospitals
PACE Hospitals’ expert Gastroenterology team successfully performed Peroral Endoscopic Myotomy (POEM) on a 25-year-old male patient from Bangladesh diagnosed with Type II achalasia cardia. The procedure was performed to relieve the functional obstruction at the lower end of the oesophagus, improve swallowing, and enable the patient to eat more comfortably.
Chief Complaints
A 25-year-old male patient with a body mass index (BMI) of 17 presented to the Gastroenterology Department at PACE Hospitals, Hitech City, Hyderabad, with difficulty swallowing food. His symptoms had progressively affected his ability to eat comfortably and prompted further evaluation and treatment.
Past Medical History
The patient was a known case of Type II achalasia cardia, previously diagnosed at a local healthcare facility in Bangladesh. There was no documented history of significant medical comorbidities, prior gastrointestinal surgeries, or other relevant chronic illnesses.
On Examination
On examination, the patient was conscious, coherent, and oriented, and was hemodynamically stable. General physical examination was normal. Abdominal examination revealed a soft, non-distended, and non-tender abdomen without guarding, rigidity, rebound tenderness, or palpable organomegaly. Bowel sounds were present, and cardiovascular, respiratory, and neurological examinations were within normal limits.
Diagnosis
Upon admission to PACE Hospitals, the patient was thoroughly evaluated by the Gastroenterology team with a known diagnosis of Type II achalasia cardia and persistent symptoms requiring definitive treatment. Clinical assessment raised the need for comprehensive evaluation to confirm the diagnosis and determine the most appropriate therapeutic approach.
A detailed diagnostic workup was performed. Esophageal manometry confirmed Type II achalasia cardia with impaired lower esophageal sphincter relaxation. Integrated relaxation pressure (IRP) findings were consistent with the diagnosis, while a barium swallow study demonstrated characteristic features of achalasia. Upper gastrointestinal endoscopy revealed a normal gastric fundus and findings consistent with achalasia, with the gastroesophageal junction appearing anatomically normal. Based on the clinical findings and diagnostic investigations, the diagnosis of Type II achalasia cardia was confirmed.
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.
Medical Decision-Making (MDM)
After a detailed consultation with the consultant gastroenterologists, Dr. Govind Verma and Dr. M. Sudhir, along with the therapeutic endoscopy team, a comprehensive clinical evaluation was performed. The patient's confirmed diagnosis of Type II achalasia cardia, along with the findings from esophageal manometry, integrated relaxation pressure assessment, barium swallow study, and upper gastrointestinal endoscopy, were thoroughly reviewed to determine the most appropriate treatment strategy.
Based on this multidisciplinary assessment, Peroral Endoscopic Myotomy (POEM) was identified as the most appropriate definitive treatment. As a minimally invasive third-space endoscopic procedure, POEM was considered the optimal approach to relieve lower esophageal sphincter obstruction, restore esophageal emptying, improve swallowing, and provide durable symptomatic relief while avoiding the need for conventional surgery.
The patient and his family were counselled regarding the diagnosis, the POEM procedure, its risks and benefits, postoperative dietary modifications, and the need for follow-up. After obtaining informed consent and completing the required pre-procedural evaluations, the patient was taken up for the procedure.
Surgical Procedure
Following the decision, the patient was scheduled for Peroral Endoscopic Myotomy (POEM) Procedure in Hyderabad at PACE Hospitals, under the expert care of the Gastroenterology Department.
The procedure was carried out in the following steps:
- Pre-procedural Preparation: After obtaining informed consent and completing all necessary investigations and clearances, the patient was prepared for the POEM procedure under general anesthesia. Intravenous antibiotics were administered, and standard endoscopic precautions were followed.
- Endoscopic Assessment and Mucosal Entry: Upper gastrointestinal endoscopy was performed, and the gastroesophageal junction was identified. A mucosal incision was created approximately 9 cm above the gastroesophageal junction using a T knife to gain access to the submucosal space.
- Submucosal Tunnel Creation: Using CO₂ insufflation for improved visualization, careful submucosal tunneling was performed through the esophageal wall. The tunnel was extended across the lower esophageal sphincter into the proximal stomach to allow access for myotomy.
- Selective Myotomy: The circular muscle fibers were divided using a Hybrid Knife, with adequate extension across the lower esophageal sphincter to relieve the functional obstruction associated with achalasia cardia. The procedure was performed under continuous endoscopic guidance.
- Closure of Mucosal Entry Site: Following completion of the myotomy, the tunnel was inspected, and the mucosal entry site was closed using Olympus endoscopic clips. The procedure was completed successfully without any intra-procedural complications.
Postoperative Care
Following the POEM procedure, the patient was shifted to the ICU for close monitoring and observation. Supportive care was provided to maintain hydration, manage post-procedural discomfort, prevent nausea and vomiting, and minimize the risk of complications. An oral Gastrografin study was performed, which showed free passage of contrast across the gastroesophageal junction without leakage or retention, confirming procedural success. The patient remained clinically stable and was advised regular follow-up.
Discharge Medications
Upon discharge, the patient was prescribed supportive medications indicated for infection prophylaxis, pain relief, prevention of nausea and vomiting, and gastric mucosal protection. The patient was advised to continue the prescribed treatment as directed.
Advice on Discharge
The patient was advised to follow a gradual diet progression as tolerated, starting with liquids and advancing as per medical advice. He was instructed to take small meals, maintain adequate hydration, chew food thoroughly, and consume lukewarm water after meals to support recovery.
Emergency Care
The patient was advised to contact the emergency ward at PACE Hospitals in case of any emergency or development of symptoms such as fever, vomiting, abdominal pain, or any other concerning complaints following the procedure.
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 one month.
Conclusion
This case highlights the effectiveness of Peroral Endoscopic Myotomy (POEM) in the treatment of Type II achalasia cardia, providing significant symptomatic improvement through a minimally invasive approach. The successful procedure resulted in improved swallowing ability and overall patient recovery. This case emphasizes the role of advanced endoscopic interventions in achieving favorable outcomes in achalasia management.
Role of POEM in Achalasia Cardia Management
Peroral Endoscopic Myotomy (POEM) is an advanced minimally invasive endoscopic procedure that has transformed the management of achalasia cardia. Under the expertise of a skilled gastroenterologist/gastroenterology doctor, POEM helps reduce lower esophageal sphincter obstruction by creating a submucosal tunnel and selectively dividing the dysfunctional muscle fibers to improve esophageal emptying. As a third-space endoscopic technique, it requires specialized training, advanced equipment, and precise procedural skills to ensure safety and effectiveness. POEM offers benefits such as reduced invasiveness, faster recovery, and significant improvement in swallowing symptoms compared with conventional surgical approaches. Appropriate patient evaluation, careful procedural planning, and regular follow-up are essential for achieving optimal long-term outcomes.
Frequently Asked Questions(FAQs)
Is POEM effective for Type II achalasia cardia?
Yes. POEM is commonly used to treat Type II achalasia in suitable patients. During the procedure, the tight muscle at the lower end of the oesophagus is divided so that food and liquids can enter the stomach more easily. Most patients notice a clear improvement in swallowing. Before recommending POEM, the doctor considers the test results, age, general health, previous treatment, and overall condition of the patient.
Why are oesophageal manometry and a barium swallow done before POEM?
Oesophageal manometry shows how well the muscles of the oesophagus are working and whether the lower oesophageal sphincter is relaxing normally. It also helps the doctor identify the type of achalasia. A barium swallow tracks the movement of contrast through the food pipe and shows where it is slowing down. These tests confirm the diagnosis and help the endoscopist plan the treatment correctly.
How does POEM improve swallowing without open surgery?
POEM is performed through the mouth with the help of a flexible endoscope. A small opening is made in the inner lining of the oesophagus, and a tunnel is created within the oesophageal wall. The tight muscle fibres causing the blockage are then cut. At the end of the procedure, the opening is closed with clips. Since there are no cuts on the chest or abdomen, recovery is often smoother.
How is POEM different from balloon dilation or Heller myotomy?
These treatments all help improve swallowing by reducing tightness at the lower end of the oesophagus. Balloon dilation widens the narrowed area using an inflatable balloon. Heller myotomy is a surgical procedure in which the tight muscle is cut through small abdominal incisions. POEM also cuts the affected muscle, but it is carried out through the mouth using an endoscope, without any external incision. The most suitable option is decided after considering the type of achalasia, previous treatment, reflux risk, and the patient’s overall health.
Why is a Gastrografin swallow test done after POEM?
The Gastrografin swallow test is done to check whether the contrast liquid is moving freely from the oesophagus into the stomach. It also helps the doctor look for any leakage from the treated area. In this case, the contrast passed smoothly across the gastroesophageal junction and there was no leakage. Once the medical team confirmed that the result was satisfactory, the patient was allowed to begin oral liquids.
When can a patient start eating after POEM?
Eating and drinking are restarted only after the doctor confirms that the patient is recovering well. The diet usually begins with clear liquids and is gradually changed to liquid, semisolid, and soft foods. In this case, the patient was advised to take a liquid diet for three days and a semisolid diet for the next five days. Small meals, slow eating, and proper chewing are helpful during recovery.
Is ICU observation always required after POEM?
No. Every patient does not need ICU care after POEM. Some patients can be safely monitored in a regular ward. ICU observation may be advised depending on the patient’s health, recovery from anaesthesia, hospital protocol, and how the procedure went. In this case, the patient was kept in the ICU for closer monitoring of vital signs, pain, swallowing, and any early post-procedure concerns.
Which symptoms after POEM require immediate medical attention?
The treating team should be contacted immediately if the patient develops fever, severe chest pain, abdominal pain, repeated vomiting, breathing difficulty, blood in the vomit, black stools, increasing abdominal swelling, fainting, or difficulty swallowing liquids. These symptoms should not be ignored, even if they appear mild at first. Early medical assessment helps the doctor rule out bleeding, infection, leakage, or another complication.
Can acid reflux occur after POEM?
Yes. Acid reflux can develop after POEM because the procedure loosens the muscle between the oesophagus and stomach. While this makes swallowing easier, it may also allow stomach acid to move upwards. Some patients experience heartburn, a sour taste, chest discomfort, coughing, or food coming back into the mouth. Others may not notice any symptoms. Acid-reducing medicines or follow-up tests may be advised when needed.
Can swallowing difficulty return after POEM?
POEM gives long-term relief to many patients, but achalasia is a chronic condition. In some cases, swallowing problems may return because of scarring, incomplete muscle division, changes in the oesophagus, or narrowing caused by reflux. Regular follow-up is therefore important, even when the patient feels well. If swallowing difficulty comes back, the doctor may advise endoscopy, manometry, a barium swallow, or further treatment.
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