Open peroral endoscopic myotomy for refractory benign esophageal stricture

A 36-year-old woman suffered thoracic pain and dysphagia following a barbecue 6 months earlier. Gastroscopy showed an ulcer in the lower esophagus. The thoracic pain disappeared after taking proton pump inhibitors (PPIs) for a week, but dysphagia continued. Repeat gastroscopy showed a thickened and rigid lower esophageal wall and esophageal stricture ([Fig. 1 a]). The stricture was about 4.0 cm from the cardia. Endoscopic biopsy diagnosed inflammation. Esophagography showed severe stricture in the lower esophagus ([Fig. 2 a]). Thoracic computed tomography showed a thickened lower esophageal wall, and endoscopic ultrasonography showed thickening of the muscularis propria in the lower esophagus ([Fig. 3]), without manifestation of tumors. The patient continued to take PPIs and underwent three sessions of endoscopic dilation, without success; she lost 8.0 kg in weight.

Fig. 1 Gastroscopy. a Pre-procedure, showing a thickened and rigid lower esophageal wall and a stricture. b At follow-up, showing that the incision had healed well, with only mild stricture remaining.

Fig. 2 Esophagography. a Pre-procedure, showing severe stricture of the lower esophagus. b At follow-up, showing significant improvement, with only mild stricture.

Fig. 3 Endoscopic ultrasonography showed a thickened muscularis propria in the lower esophagus.

We performed open peroral endoscopic myotomy (O-POEM) ([Video 1]). The mucosal and circular muscle layers of the stricture were incised completely without submucosal tunnel creation ([Fig. 4]), and with the upper and lower edge incisions extending about 2.0 cm beyond the stricture.

Video 1 The lower esophagus was rigid and strictured, and the mucosal and circular muscle layers of the stricture were incised completely without submucosal tunnel creation.

Fig. 4 The mucosal and circular muscle layers of the stricture were incised completely without submucosal tunnel creation.

The patient recovered uneventfully after endoscopic treatment and gradually returned to a normal diet. Her body weight had increased by 4.0 kg at 6 months after treatment. Follow-up esophagography showed that the stricture had significantly improved post-procedure ([Fig. 2 b]). Follow-up gastroscopy showed that the original esophageal incision had healed well and the lumen was only mildly strictured ([Fig. 1 b]), with smooth passage of the endoscope.

Endoscopic balloon dilation [1] or stenting [2] is an effective treatment for benign esophageal stricture. Radial incision and cutting [3] can also be performed. Due to the poor effect of balloon dilation, the rigid wall, and the presence of stricture, we performed O-POEM for this patient. O-POEM is a safe and effective treatment for achalasia [4], as well as an effective therapy for benign esophageal stricture.

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Competing interests

The authors declare that they have no conflict of interest.

^* These authors contributed equally to this work.

• References

• 1 Osuga T, Ikura Y, Hasegawa K. et al. Use of endoscopic balloon dilation for benign esophageal stenosis in children: our 11 year experience. Esophagus 2018; 15: 47-51
• 2 Dall’Oglio L, Caldaro T, Toschia F. et al. Endoscopic management of esophageal stenosis in children: new and traditional treatments. World J Gastrointest Endosc 2016; 8: 212-219
• 3 Mizusawa T, Kobayashi M, Terai S. Radial incision and cutting for refractory benign esophageal stricture. Dig Endosc 2019; 31: e46-e47
• 4 Liu W, Zeng HZ, Yuan XL. et al. Open peroral endoscopic myotomy for the treatment of achalasia: a case series of 82 cases. Dis Esophagus 2019; 32: 1-7

Publication History

Article published online:
29 January 2020