Successful POEM Procedure Relieved Severe Dysphagia in a 69 Y.O. Male with Type II Achalasia

Chief Complaints

A 69-year-old male patient with a body mass index (BMI) of 18 presented to the Gastroenterology Department at PACE Hospitals, Hitech City, Hyderabad, with complaints of severe difficulty in swallowing (dysphagia) for both liquids and solids, along with vomiting immediately after eating.

The patient was a known case of hypertension and was on regular antihypertensive medication. There was no history of diabetes mellitus, significant cardiac disease, or any other major medical comorbidities.

On examination, the patient was conscious, coherent, oriented, and hemodynamically stable. General physical examination was normal. Systemic examination did not reveal any significant cardiovascular, respiratory, or neurological abnormalities. The patient's clinical presentation was consistent with esophageal motility disorder causing severe dysphagia.

Upon admission to PACE Hospitals, the patient was evaluated by the Gastroenterology team for severe dysphagia to both liquids and solids, along with postprandial vomiting. A detailed clinical assessment and review of the patient's medical history were performed.

Esophageal manometry, performed prior to admission, demonstrated increased lower esophageal sphincter (LES) pressure, impaired sphincter relaxation, and panesophageal pressurization, findings characteristic of Type II achalasia cardia. These findings confirmed impaired esophageal motility as the cause of the patient's swallowing difficulty. Routine preoperative investigations, including blood tests, imaging, cardiology evaluation, and pre-anesthetic assessment, confirmed that the patient was fit for intervention.

Based on the confirmed diagnosis, the patient was advised to undergo Type II Achalasia Cardia Treatment in Hyderabad, India, under the expert care of the Gastroenterology Department. 

After a detailed consultation with Dr. Govind Verma (Interventional Gastroenterologist and Hepatologist) and Dr. M. Sudhir (Senior Consultant Gastroenterologist and Hepatologist), a comprehensive clinical evaluation was performed to determine the most appropriate treatment approach.

Considering the patient's severe dysphagia to both liquids and solids, postprandial vomiting, and esophageal manometry findings confirming Type II achalasia cardia, it was determined that the symptoms were caused by impaired relaxation of the lower esophageal sphincter, leading to obstruction of food passage into the stomach. Routine preoperative investigations, including blood tests, imaging, cardiology evaluation, and pre-anesthetic assessment, confirmed that the patient was fit for intervention.

Based on the clinical assessment and diagnostic findings, it was determined that Peroral Endoscopic Myotomy (POEM) was the most appropriate treatment strategy. The procedure was planned to divide the abnormally tight lower esophageal sphincter, restore normal passage of food and liquids into the stomach, relieve dysphagia and postprandial vomiting, and provide the benefits of a minimally invasive endoscopic approach with faster recovery.

The patient and his family members were counselled regarding the diagnosis, the planned endoscopic procedure, its expected benefits, potential risks, postoperative dietary progression, recovery, and the importance of regular follow-up.

Following the decision, the patient was scheduled to undergo a Peroral Endoscopic Myotomy (POEM) procedure in Hyderabad at PACE Hospitals, under the expert care of the Gastroenterology Department.

The procedure involved the following steps:

• Patient Preparation and Anaesthesia: The patient was kept fasting before the procedure and underwent pre-anesthetic evaluation. Under general anaesthesia, standard aseptic precautions were followed, and continuous monitoring was maintained throughout the procedure.

• Upper Gastrointestinal Endoscopy and Mucosal Entry: An upper gastrointestinal endoscopy was performed to assess the esophagus and gastroesophageal junction. A mucosal incision was created in the esophagus, and a submucosal tunnel was carefully developed to reach the lower esophageal sphincter.

• Submucosal Tunnelling and Myotomy: The submucosal tunnel was extended across the gastroesophageal junction. A precise endoscopic myotomy was then performed by dividing the circular muscle fibres of the lower esophageal sphincter to relieve the functional obstruction and restore normal passage of food.

• Closure of Mucosal Entry: After confirming adequate myotomy and haemostasis, the mucosal entry site was securely closed using endoscopic clips.

• Completion of the Procedure: Final endoscopic assessment confirmed successful completion of the myotomy without any intraoperative complications. The patient was shifted for postoperative monitoring and further care.
  

Following the procedure, the patient was closely monitored for pain, fever, vomiting, difficulty swallowing, abdominal discomfort, and any signs of procedure-related complications. He was kept nil by mouth for 2 days and received intravenous fluids, infection prevention, gastric acid suppression, and other supportive care during the immediate recovery period.

An oral Gastrografin study was subsequently performed, which demonstrated free flow of contrast across the gastroesophageal junction without retention or leakage, confirming successful myotomy and the absence of perforation. The patient remained clinically stable, and a liquid diet was gradually initiated, which he tolerated well.

Upon discharge, the patient was prescribed medications for infection prevention, gastric protection, pain relief, blood pressure control, nutritional support, and other supportive care as required. He was advised to take all medications exactly as prescribed and to continue regular follow-up with the treating Gastroenterologist.

The patient was advised to follow a liquid diet for 5 days, followed by a soft diet for the next 5 days before gradually resuming a normal diet as tolerated. He was instructed to avoid very cold liquids, eat slowly, consume small frequent meals, chew food thoroughly, maintain adequate hydration, and follow all dietary instructions.

The patient was advised to report immediately to the emergency ward at PACE Hospitals in case of fever, severe chest or abdominal pain, persistent vomiting, difficulty swallowing, inability to tolerate liquids, breathing difficulty, or any other emergency symptoms.

The patient was advised to return for a follow-up visit with the Gastroenterologist in Hyderabad at PACE Hospitals after 1 month.

This case highlights the successful management of Type II achalasia cardia with Peroral Endoscopic Myotomy (POEM). The procedure was completed successfully without any immediate complications. The patient showed significant improvement in swallowing, tolerated oral liquids well after the procedure, and was discharged in a hemodynamically stable condition with appropriate dietary advice, medications, and regular follow-up recommendations.