Radiologic Findings Portable upright AP (Fig. 1A) and edge-enhanced (Fig. 1B) frontal chest radiographs shows multiple metallic linear opacities in a stacked configuration overlying the azygos-esophageal recess. There is mild basilar under aeration. No post-procedural pneumothorax or pneumomediastinum is identified (Radiologic images and case write-up provided by Britt Groseclose, MD and Leila Rezai, MD, VCU Health, Department of Diagnostic Radiology). Answer Diagnosis: Esophageal endoscopic mucosal clips; status post Per-Oral Endoscopic Myotomy (POEMS)
Esophageal endoscopic mucosal clips; status post Per-Oral Endoscopic Myotomy (POEMS)
Answer
Diagnosis: Esophageal endoscopic mucosal clips; status post Per-Oral Endoscopic Myotomy (POEMS)
Differential diagnosis:
· External object overlying patient
· Other surgical material
· Ingested foreign bodies lodged in esophagus
Discussion:
Per-Oral Endoscopic Myotomy (POEM) is a minimally invasive endoscopic procedure for the treatment of symptomatic idiopathic achalasia, confirmed by manometry. Other esophageal disorders treated with POEM include: spastic esophageal disorders such as diffuse esophageal spasm and Jackhammer esophagus.
Brief Description of the POEM procedure:
The first phase of the procedure entails an endoscopic mucosal incision approximately 3.0 cm superior to the proposed myotomy site, proximal to the lower esophageal sphincter. Subsequently, a submucosal tunnel is created distally, extending beyond the gastroesophageal junction. Next, a selective myotomy of the inner circular muscle is performed while preserving the outer longitudinal esophageal muscular layer. Preservation of the outer muscle layer is necessary to prevent inadvertent entry of the pleural cavity by the endoscope. Following the myotomy, the esophageal defect is closed using radio-opaque endoscopic clips (Figure 2). These clips remain in place for several days to weeks. As the mucosa heals, the clips spontaneously detach and pass down the gastrointestinal tract and are expelled from the body.
The most frequently utilized post-procedure imaging techniques include conventional radiography (Fig. 1A and 1B) and fluoroscopy. Sequelae of the procedure identified on post-procedural imaging may include subcutaneous air and pneumoperitoneum. Pneumothorax and pneumomediastinum are observed less frequently unless the outer longitudinal esophageal muscle layer has been violated. The most feared complication is esophageal perforation related to a mucosotomy.
Selected Readings:
1. Kumbhari V, Khashab MA. Peroral endoscopic myotomy. World J Gastrointest Endosc . 2015 May 16; 7(5): 496–509.
2. Von Renteln D , Fuchs KH , Fockens P , Bauerfeind P , Vassiliou MC , Werner YB , Fried G , Breithaupt W , Heinrich H , Bredenoord AJ , Kersten JF , Verlaan T , Trevisonno M , Rösch T . Peroral endoscopic myotomy for the treatment of achalasia: an international prospective multicenter study. Gastroenterology. 2013 Aug; 145(2): 309-11.e1-3. Doi: 10.1053/j.gastro.2013.04.057. Epub 2013 May 9.
3. Ortega JA, Madureri V, Perez L. Endoscopic myotomy in the treatment of achalasia. Gastrointest Endosc. 1980 Feb; 26(1): 8-10.
4. Pasricha PJ, Hawari R, Ahmed I, Chen J, Cotton PB, Hawes RH, Kalloo AN, Kantsevoy SV, Gostout CJ. Submucosal endoscopic esophageal myotomy: a novel experimental approach for the treatment of achalasia. Endoscopy. 2007; 39:761–764.
(Click for a larger image.)
Original case written by its authors at Virginia Commonwealth University and published at this address as part of a weekly teaching collection. Reproduced here as an archive.
