Peroral endoscopic myotomy (POEM) for diffuse esophageal spasm.

esophageal spasm Diffuse esophageal spasm (DES) is a rare esophageal dysmotility condition characterized by simultaneous contractions of the distal esophagus and manifested by dysphagia and chest pain. Pharmacological therapy, endoscopic interventions, and surgical myotomy have been linked to various outcomes [1,2]. Recently, peroral endoscopic myotomy (POEM) has been introduced as an effective and less invasive treatment for achalasia [3]. We report here our clinical experiences of POEM for DES. Patient 1 was an 84-year-old woman with a 5-year history of dysphagia accompanied by excessive weight loss. Esophagogastroduodenoscopy (EGD) and manometry revealed severe simultaneous contractions in the lower esophagus (●" Fig.1 and ●" Fig.2) and POEM was applied. A myotomy of 15.0cm in length was performed longitudinally to include each contraction segment (●" Fig.3). Subjective dysphagia symptom scores and pressure study were markedly improved (●" Fig.2 and ●" Fig.4). EGD after POEM showed complete absence of abnormal contractions in the incised esophagus (●" Fig.1). Patient 2was a 79-year-oldmanwith a 20year history of dysphagia, vomiting, and excessive weight loss. Endoscopic passage was impossible during the simultaneous contractions. Esophagography showed corkscrew-shaped contractions andblockage of bariumpassage at the proximal portion of contractions (●" Fig.5). The maximum pressure at the contraction site was 256.0mmHg. A 10-cm myotomy was successfully performed according to the findings of the Esophagography and manometry. Esophagography after POEM revealed complete absence of abnormal contractions on the incised anterior esophagus (●" Fig.5). Details of the results are shown in ●" Table1. No recurrence of dysphagia or postoperative gastroesophageal reflux disease has been observed in either patient since the procedures (5 and 6 months, respectively, at the time of writing). The length of myotomy was decided according to the findings of esophagography and manometry. As expected, the patients’ symptoms disappeared completely. In contrast to surgical myotomy, which requires additional antireflux procedures, POEM does not cause any destruction of the tissues surrounding the esophagogastric junction. These topics should be investigated further. Fig.1 Left image shows the abnormal simultaneous contractions before peroral endoscopic myotomy. The scope passed through the contraction segment with moderate resistance. Post-procedural esophagoscopy showed that the contractions were not seen on the anterior side of the muscle incision (right image).