Introduction Achalasia is an oesophageal motor disorder due to inhibitory neuron dysfunction, resulting in loss of oesophageal peristalsis and impaired lower oesophageal sphincter relaxation. POEM is emerging as a viable alternative to laparoscopic Heller’s myotomy (LHM) for the treatment of achalasia. However, it is still in it’s infancy in the West with no reported cases from UK.

We aim to present two videos and discuss the technical details of the procedure in a simple type II achalasia and in a complex sigmoid achalasia.

Methods Prior to undertaking POEM patients are investigated with barium swallow, gastroscopy and high-resolution manometry to confirm the diagnosis of achalasia and delineate the anatomy of the oesophagus. Eckhardt score is calculated pre and post POEM. Informed consent is undertaken, including alternatives to POEM: LHM, pneumatic dilatation and Botox injection. The procedure steps include (video): 1. Submucosal injection and incision 2. Creation of submucosal tunnel 3. Endoscopic myotomy 4. Closure of mucosal entry.

Results Case 1: A 61 year-old lady, presenting with dysphagia, retrosternal chest pain and regurgitation (Eckhardt score 6). Barium swallow demonstrated typical appearances of achalasia (see video). Pre-POEM manometry confirmed Type II achalasia with a resting lower oesophageal sphincter (LOS) pressure of 26. She underwent an uneventful POEM procedure via the anterior approach using a combination of flush-knife and triangular tip knife to achieve a 10+4 cm myotomy. On follow-up she has no symptoms (Eckhardt score 0) and repeat manometry shows a reduction in LOS pressure to 15.

Case 2: A 52 year-old lady, presenting with dysphagia, retrosternal chest pain, regurgitation and weight loss (Eckhardt score 11). Barium swallow demonstrated advanced achalasia with severe dilatation and a sigmoid appearance (see video). She was treated at her local centre with two sessions of PD and one of Botox despite which she suffered ongoing symptoms. Pre-POEM manometry revealed Type II achalasia and an LOS pressure of 25.5. She underwent an uneventful POEM procedure via the posterior approach using the O-type Erbe hybrid knife to achieve an 11 + 4 cm myotomy. Significant fibrosis was encountered due to previous intervention. On follow-up her symptoms improved significantly. Repeat manometry is awaited.

Conclusion

• Here we describe the technique of POEM at the two ends of the disease spectrum of achalasia

• We demonstrate the feasibility of the technique in the hands of a UK Endoscopist.

• We demonstrate two different approaches to POEMS (Anterior vs Posterior) and with two different knives and will discuss the Pros and Cons of these approaches.

• Despite previous intervention and submucosal fibrosis, POEM is still a viable treatment for patients with ongoing symptoms.

Disclosure of Interest None Declared