Double trouble during peroral endoscopic myotomy for achalasia cardia: myotomy to the rescue

Peroral endoscopic myotomy (POEM) is now the established modality of choice for achalasia cardia with good long-term efficacy [ 1 ]. Dislodgement of the distal attachment (hood) inside the tunnel is an uncommon intraoperative event. The retrieval of a dislodged hood can be troublesome at or beyond the lower esophageal sphincter (LES). Here we share a case of POEM for achalasia cardia where the patient developed a dual problem of a type II mucosal injury and dislodgement of the hood at the level of the LES that was tackled with myotomy. A 55-year-old woman with diagnosis of achalasia cardia was planned for POEM. During tunneling at the level of the LES, an inadvertent type II mucosal injury occurred due to twisting of the axis of the tunnel ([ Video 1 ], [ Fig. 1 ]). The endoscope was withdrawn to assess the extent of injury from the luminal side. However, during the process the hood became dislodged and stuck at the distal end of the LES ([ Fig. 2 ]). Attempts to retrieve the dislodged hood with a rat tooth forceps were futile. Moreover, the hood was impinging on the mucosal injury ([ Fig. 3 ]). Hence, a further attempt with forceps was abandoned due to the fear of extending the injury by manipulation of the forceps. Thus, myotomy was started to loosen the hood inside the tunnel and reduce pressure on the mucosal injury ([ Fig. 4 ]). After cutting the LES, the hood was successfully retrieved ([ Fig. 5 ]). Later, careful dissection of the LES was done, avoiding any further extension of the mucosal injury. Then a gastric myotomy was extended for 3 cm. The mucosal injury was secured with hemoclips followed by closure of the mucosal incision. Fig. 1 White arrow shows type II mucosal injury at the level of lower esophageal sphincter. Fig. 2 Dislodged hood inside the tunnel at the distal end of lower esophageal sphincter. Fig. 3 White arrow shows bulging hood through the mucosal injury. Fig. 4 Myotomy of the lower esophageal sphincter to loosen the hood inside the tunnel that will help in its retrieval as well as reduce pressure on the mucosal injury. Fig. 5 Retrieved hood from inside the tunnel. Video 1 Video demonstrating the dual benefit of myotomy in retrieval of a hood stuck at the lower esophageal sphincter along with prevention of mucosal injury extension. Quality: mobile 360 480 720 Download This case demonstrates the dual benefit of myotomy in retrieval of a hood stuck at/beyond the LES along with prevention of any extension of mucosal injury if it occurs at the site of the dislodged hood. Endoscopy_UCTN_Code_CPL_1AH_2AJ Endoscopy E-Videos https://eref.thieme.de/e-videos Endoscopy E-Videos is an open access online section, reporting on interesting cases and new techniques in gastroenterological endoscopy. All papers include a high quality video and all contributions are freely accessible online. Processing charges apply, discounts and wavers acc. to HINARI are available. This section has its own submission website at https://mc.manuscriptcentral.com/e-videos Publication History Article published online: 17 March 2023 © 2023. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/) Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany