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Case of early Barrett cancer following peroral endoscopic myotomy
  1. Yervant Ichkhanian1,
  2. Petros Benias2,
  3. Mouen A Khashab1
  1. 1Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, USA
  2. 2Division of Gastroenterology, Department of Medicine, Hofstra Northwell School of Medicine, Northwell Health System, North Shore University Hospital, Manhasset, New York, USA
  1. Correspondence to Dr Mouen A Khashab, Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, MD 21287, USA; mkhasha1{at}jhmi.edu

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Peroral endoscopic myotomy (POEM) offers an effective and a minimally invasive approach for the management of patients with achalasia and is now considered the standard of care at many centres around the world. Despite its excellent outcomes, the high incidence of postoperative GORD remains its major limitation. Unlike laparoscopic Heller myotomy (LHM), no concomitant fundoplication is performed during POEM, which can increase the incidence of GORD and its long-term consequences. Recently, we diagnosed a case of de novo Barrett’s oesophagus (BE) with oesophageal adenocarcinoma in a patient, 4 years after POEM was performed for achalasia, highlighting the possible long-term consequences of postprocedural GORD.

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Since it was first clinically described,1 POEM has gained worldwide acceptance as an endoscopic technique for the management of achalasia. Despite its well-established efficacy and safety, the development of GORD post-POEM remains a major concern.2 Of particular concern is that up to two-thirds of patients have asymptomatic and unrecognised GORD.3 The effectiveness of our current management and monitoring strategies for GORD following POEM is not well established. In addition, long-term data pertinent to chronic oesophageal acid exposure after POEM are lacking.

The following case is of a 69-year-old man who initially presented at the age of 64 with a 15-year history of dysphagia, regurgitation, microaspiration and intermittent chest pain, and high-resolution oesophageal manometry (HREM) was consistent with type III achalasia. Impedance-pH study was negative for underlying gastro-oesophageal reflux (GER), and the patient had no additional pertinent medical, surgical or family history.

POEM was performed with a 17 cm oesophageal myotomy and 2 cm gastric myotomy with no adverse events. Postprocedure, the distensibility index increased from a baseline value of 1.7 mm2/mm Hg to 6.3 mm2/mm Hg using the endoluminal functional lumen imaging probe (EndoFLIP), and oesophagram revealed proper lower oesophagus emptying with no …

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