Successful Peroral Endoscopic Myotomy (POEM) for Type II Achalasia in a 46 Y.O. Female
PACE Hospitals
PACE Hospitals’ expert Gastroenterology team successfully performed a Peroral Endoscopic Myotomy (POEM) Procedure on a 46-year-old female patient diagnosed with Type II achalasia cardia. The procedure was undertaken to relieve the functional obstruction at the lower esophageal sphincter, improve the passage of food and liquids into the stomach, relieve swallowing difficulty, and improve the patient’s overall quality of life.
Chief complaints
A 46-year-old female patient with a
body mass index (BMI) of 19 presented to the Gastroenterology Department at
PACE Hospitals, Hitech City, Hyderabad, with complaints of severe difficulty in swallowing both liquids and solids for the past 7 months, along with a sensation of food getting stuck.
Past Medical History
The patient was a known case of
hypertension and was on regular treatment. There was no history of
diabetes mellitus, cardiac disease, significant gastrointestinal illness, or other major chronic medical conditions.
On Examination
On examination, the patient was conscious, coherent, and oriented, with stable vital signs except for elevated blood pressure. General physical examination was otherwise normal. Abdominal examination did not reveal any palpable mass or significant abnormality. Respiratory examination showed no signs of acute distress, 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 severe difficulty in swallowing both liquids and solids for the past 7 months, associated with a sensation of food getting stuck.
A comprehensive diagnostic workup was performed, including upper gastrointestinal endoscopy (UGI endoscopy) and esophageal manometry. The findings were consistent with Type II achalasia cardia, indicating impaired relaxation of the lower oesophageal sphincter and abnormal oesophageal emptying. A chest X-ray (AP view) was also performed as part of the pre-procedure evaluation. Routine investigations, including blood tests and other preoperative assessments, were performed to evaluate the patient's overall condition and fitness for the planned procedure.
Based on the confirmed diagnosis, the patient was advised to undergo
Type II Achalasia Cardia Treatment in Hyderabad, India, under the expert care of the Gastroenterology Department.
Medical Decision Making (MDM)
After a detailed consultation with Dr. Govind Verma (Interventional Gastroenterologist and Hepatologist) and Dr. M. Sudhir (Senior Consultant Gastroenterologist and Hepatologist), a comprehensive clinical evaluation was performed to determine the most appropriate diagnostic and therapeutic approach for the patient presenting with severe difficulty in swallowing both liquids and solids for the past 7 months, along with a sensation of food getting stuck.
Considering the patient's clinical presentation, esophageal manometry and upper gastrointestinal endoscopy findings consistent with Type II achalasia cardia, along with the pre-procedure assessment including chest X-ray, the treatment strategy was formulated. The patient was assessed for fitness for the planned endoscopic intervention.
Based on the clinical findings and diagnostic evaluation, it was determined that Peroral Endoscopic Myotomy (POEM) was the most appropriate treatment strategy. The procedure was planned to relieve the functional obstruction at the lower oesophageal sphincter, improve oesophageal emptying, relieve dysphagia, and facilitate more comfortable intake of food and liquids.
The patient and her family members were counselled regarding the diagnosis, proposed endoscopic procedure, expected benefits, potential risks, postoperative dietary progression, recovery process, and the importance of follow-up. Informed consent was obtained before proceeding with the procedure.
Surgical Procedure
Following the clinical evaluation and confirmation of the diagnosis, the patient was scheduled to undergo a Peroral Endoscopic Myotomy (POEM) procedure in Hyderabad at PACE Hospitals, under the expert care of the Gastroenterology Department.
The procedure involved the following steps:
- Patient Preparation and Anaesthesia: The patient was kept fasting before the procedure and underwent the required pre-procedure evaluation. General anaesthesia with appropriate airway protection was administered, and standard aseptic precautions were maintained throughout the procedure.
- Upper Gastrointestinal Endoscopy: An upper gastrointestinal endoscopy was performed to assess the esophagus, gastroesophageal junction, and stomach. The gastroesophageal junction was evaluated to determine the extent of functional obstruction.
- Mucosal Entry and Submucosal Tunnelling: A small mucosal incision was created in the oesophageal wall to gain access to the submucosal layer. A submucosal tunnel was then carefully created and extended towards the gastroesophageal junction.
- Endoscopic Myotomy: The circular muscle fibres of the lower oesophageal sphincter and gastroesophageal junction were carefully divided using an endoscopic knife. This myotomy reduced the abnormal muscular tightness and relieved the functional obstruction responsible for the patient's dysphagia.
- Haemostasis and Mucosal Closure: Any visible bleeding points were appropriately managed to achieve haemostasis. After confirming adequate myotomy, the mucosal entry site was securely closed using endoscopic clips.
- Completion of the Procedure: The gastroesophageal junction was reassessed endoscopically, and improved passage across the junction was confirmed. The procedure was completed successfully without immediate complications, and the patient was shifted for postoperative monitoring.
Postoperative Care
Following the procedure, the patient was closely monitored for chest or abdominal pain, fever, vomiting, difficulty swallowing, and other signs of procedure-related complications. She received intravenous fluids for hydration, medicines to prevent infection, medicines to reduce gastric acid production and protect the esophageal lining, pain-relieving treatment, and other supportive care as required. The postoperative recovery was uneventful, and the patient remained hemodynamically stable.
Discharge Medications
Upon discharge, the patient was prescribed medicines to reduce gastric acid and protect the esophageal lining, prevent infection, relieve pain and postoperative discomfort, and manage other symptoms as required. She was advised to take all prescribed medicines as directed and continue her regular treatment for blood pressure control.
Advice on Discharge
The patient was advised to follow a clear liquid diet for 7 days, followed by a liquid diet for another 7 days, and then gradually transition to a soft diet as tolerated. She was advised to maintain adequate hydration, eat slowly, and follow the dietary progression recommended by the treating Gastroenterology team.
Emergency Care
The patient was advised to report immediately to the
emergency ward at PACE Hospitals in case of fever, severe chest or abdominal pain, persistent vomiting, difficulty swallowing, inability to tolerate liquids, breathing difficulty, bleeding, or any other emergency symptoms.
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 6 weeks.
Conclusion
This case highlights the successful management of Type II achalasia cardia using Peroral Endoscopic Myotomy (POEM). The minimally invasive procedure was completed successfully without intraoperative complications. The patient had an uneventful postoperative recovery and was discharged in a hemodynamically stable condition with appropriate dietary advice, supportive treatment, and scheduled follow-up.
Minimally Invasive Management of Type II Achalasia Cardia with POEM
Type II achalasia cardia causes impaired relaxation of the lower esophageal sphincter, resulting in difficulty swallowing and impaired passage of food into the stomach. Peroral Endoscopic Myotomy (POEM) provides a minimally invasive approach to relieve this functional obstruction by creating a submucosal tunnel and dividing the abnormal muscle fibres at the gastroesophageal junction. Proper patient evaluation, esophageal manometry, endoscopic assessment, and pre-procedure preparation help guide treatment planning. Following POEM, gradual dietary advancement, symptom monitoring, and regular follow-ups with a
gastroenterologist/gastroenterology doctor are important for supporting recovery and maintaining improvement in swallowing and daily functioning.
Frequently asked questions (FAQs)
Is POEM a minimally invasive procedure?
Yes, POEM is a minimally invasive endoscopic procedure performed through the mouth, so it does not require an external surgical incision. The gastroenterologist creates a small opening in the oesophageal lining, makes a tunnel within the wall, and cuts the tight muscle fibres of the lower oesophageal sphincter to improve the passage of food into the stomach.
What diet should be followed after POEM?
Diet is usually advanced gradually after POEM to allow the treated area to heal. Patients may initially be advised to take clear liquids, followed by a liquid or soft diet before gradually returning to normal foods. The exact schedule can vary depending on recovery and the treating gastroenterologist's instructions.
Can acid reflux occur after POEM?
Yes, acid reflux can occur after POEM because the procedure reduces the pressure of the lower oesophageal sphincter, which can make it easier for stomach contents to move back into the oesophagus. Doctors may recommend medicines that reduce stomach acid along with dietary and lifestyle measures to control reflux.
Can untreated achalasia cause complications?
Yes, untreated achalasia can cause food and liquids to remain in the oesophagus, leading to progressive oesophageal enlargement, regurgitation, coughing, chest discomfort, and nutritional problems such as weight loss. In some patients, retained food can also increase the risk of aspiration into the lungs.
Why is the patient kept fasting after POEM?
Fasting after POEM allows the treated oesophageal area and mucosal entry site to begin healing and reduces the risk of complications while swallowing is temporarily restricted. Before oral intake is restarted, the treating team may perform an imaging study to check for any leakage and confirm that it is safe to begin drinking.
What foods should be avoided during recovery after POEM?
During the early recovery period, patients are generally advised to avoid solid, hard, dry, spicy, or difficult-to-swallow foods until the treating team allows them. The diet is gradually progressed from liquids to soft foods and then to a normal diet as tolerated. Eating slowly and taking small portions can also make swallowing more comfortable.
What foods should be avoided during recovery after POEM?
During the early recovery period, patients are generally advised to avoid solid, hard, dry, spicy, or difficult-to-swallow foods until the treating team allows them. The diet is gradually progressed from liquids to soft foods and then to a normal diet as tolerated. Eating slowly and taking small portions can also make swallowing more comfortable.
Can POEM be repeated if achalasia symptoms recur?
In selected patients, additional treatment may be possible if symptoms return after POEM. The cause of recurrent symptoms is first evaluated, often with endoscopy, imaging, or other appropriate tests. Depending on the findings, repeat endoscopic treatment or another treatment option may be considered by the gastroenterology team.
Does POEM permanently relax the lower esophageal sphincter?
POEM cuts the muscle fibres responsible for the abnormal tightness of the lower esophageal sphincter, providing long-lasting relief for many patients. However, it cannot restore the normal nerve function that causes achalasia. Some patients may therefore experience recurrent symptoms over time and require follow-up.
Will patients need medicines after POEM?
Some patients may need medicines after POEM, particularly to control acid reflux and support recovery. Other medicines may be prescribed temporarily depending on the patient's symptoms and clinical condition. Patients should take medicines only as directed by their treating doctor.
Can Type II achalasia be completely cured?
Achalasia is a chronic disorder of esophageal nerve and muscle function, so current treatments do not restore completely normal esophageal function. However, treatments such as POEM can effectively relieve the obstruction caused by the tight lower esophageal sphincter and provide significant, long-lasting improvement in swallowing and quality of life. Regular follow-up helps monitor long-term results and manage any recurrent symptoms.
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