Stoynov N.*, Boyanov N.*, Madzharova K.**, Todovichin K.**

*Gastroenterologist at UMHAT “Pulmed” – Plovdiv.

** Resident at UMHAT “Pulmed” – Plovdiv.

Presenting author: Stoynov N.

Correspondence: This email address is being protected from spambots. You need JavaScript enabled to view it.



Motility disorders of the esophagus are divided into primary and secondary. In their nature they can be either hyper- or hypomotility. Main clinical symptoms for both of those groups include dysphagia, chest pain, regurgitations, vomiting and at the later stages – a significant loss of weight.

Achalasia is a rare neurogenic condition with a 0,5-1/100 000 yearly worldwide incidence. It is most often characterized with aperistalism, impaired opening of the lower esophageal sphincter and mesoesophagus. Eckard score is used for a proper clinical evaluation before and after treatment. Peroral endoscopic myotomy is a relatively new method for the treatment of achalasia. It is characterized with a minimal invasiveness compared to classical Heler surgical myotomy, as well as an improvement in symptoms in 90% of the patients.



To show case series of six patients with achalasia, who were successfully treated by peroral myotomy.



The procedure is done under general anesthesia. We used a standard gastroscope Olympus EXERA II with CO2 insufflation. Making the submucosal tunnel and the myotomy was done using a triangular Olympus IT-Knife. The possible points for laying an initial cut are: front, back, front-right and back-right. Esophageal mucosa is uplifted by injecting a Gelofusine solution, dyed with Indigo carmine. The submucosal layer is made with a combination of spray coagulation, CO2 insufflation and a reinjection of solution until reaching 2 cm under the gastroesophageal junction. The mucosal cut is closed with endoscopic clips with a maximum of 2-3 mm length between every clip.



Patients showed improvement after treatment and every patient had a control endoscopy a month after the procedure and patient long-term monitoring is recommended to rule out the possibility of relapse.



Achalasia is a rare primary motility disorder of the esophagus. POEM is a minimally invasive endoscopic method of treatment. Our experience shows that in select patients, the procedure can have long term improvement of symptoms with minimal post-procedural complications. 


KEYWORDS: achalasia, POEM, esophageal motility, dysphagia