POEM procedure restored the patient’s ability to swallow | Case study

A 25-year-old male patient from Bangladesh (Rasel Parves) with a history of achalasia cardia was referred to PACE Hospitals for further treatment.

Medical History and Diagnosis

Delving deeper, it was understood that the Bangladeshi patient was experiencing issues with swallowing. Upon visiting their local healthcare centers, the patient was diagnosed with Achalasia Cardia Type II. The healthcare providers concurred that a peroral endoscopic myotomy (POEM) procedure could help in treating the disease. 

The POEM procedure falls under third space endoscopy. The third-space endoscopy (also called submucosal endoscopy) is a collective term given to a group of endoscopic techniques which operate within the submucosal domain (the wall of the gut called the submucosal space). In a few cases, third-space endoscopy also delves into muscular and subserosal layers.

Understanding that execution of the POEM procedure requires competency in third space endoscopy, with multiple cognitive and technical skills to achieve the proficiency, the patient initiated their quest for centres that perform POEM procedure with accuracy.

In their search, they came across PACE Hospitals in Hi-Tech City, Hyderabad, in India. Compared to other centers, PACE Hospitals are equipped with state-of-the-art advanced endoscopes & electrosurgical units with 3D visualization systems for POEM procedure, centralized HIMS (Hospital Information System), round-the-clock guidance from highly qualified surgeons and physicians along with minimal waiting time for both inpatient and outpatient processes among other expertise facilities – all within affordable prices. 

Course in PACE Hospitals

Upon being admitted to PACE Hospitals the diagnosis was confirmed (achalasia cardia type II) through appropriate investigations such as oesophageal manometry, integrated relaxation pressure and barium swallow test.

Treatment surgery

After consultations with the team of therapeutic endoscopists - Dr. Govind Verma, Dr. Raya Venkatesh Reddy, along with consultant gastroenterologist Dr. M Sudhir, it was determined that a peroral endoscopic myotomy (POEM) procedure was the only way to treat the patient.

With necessary investigations done & clearances obtained, the patient was administered intravenous antibiotics and later the POEM procedure was performed.

Upper gastrointestinal endoscopy was performed well, and the fundus part of the stomach was deemed normal. The gastroesophageal junction from incisors is at 42 cm which lies within the normal range (32–50 cm). CO2 insufflation was done for better visibility. At 9 cm above the gastroesophageal junction, with a T knife, submucosal tunneling was done. Circular muscle was cut with hybrid knife and the tunnel was closed with Olympus clips. The procedure was uneventful. 

The aftermath

Post surgery, the patient was shifted to ICU and was kept on observation. The necessary medicines, antibiotics, multivitamins, antiemetics, analgesics, antipyretics & other supportive care were given. 

The oral gastrograffin test was done, and it showed a free flow of gastrograffin across the gastroesophageal junction without any retention depicting a successfull outcome of the procedure. The test showed no contrast extravasation. Gradually the patient started achieving symptomatic stability and liquid diet was initiated. 

The patient was discharged haemodynamically stable and advised to take up liquid diet for three days followed by semisolid diet for five days. After every meal, lukewarm water is prescribed. The patient was also instructed to contact PACE Hospitals at once in case of fever, abdominal pain or vomiting developed.

After a month, the patient was asked to get a review by Dr. Govind Verma about his status.

The efficiency of the gastrograffin test

Orally administered diatrizoate (Gastrografin) is only absorbed in small amounts from the gastrointestinal tract in adults. After exiting the intestine (anastomotic dehiscence, perforation), gastrografin is administered via the peritoneum and is absorbed into the bloodstream by the kidneys excreted and can be detected in the ham as a white precipitate by precipitation with concentrated hydrochloric acid.

This test was first developed in 1965 by McGraw et al. described, its reliability has since been assessed differently.

The Gastrografin test appears to be a simple yet reliable test capable of being used anywhere, especially in cases of poor radiographic facilities, for immobile patients, suspicion of perforation, and in cases where the radiographic changes are positive.

This water-soluble, high osmolality contrast medium has been used diagnostically to define and therapeutically to relieve adhesive small bowel obstructions (SBO). Experimental and proof-of-concept studies have demonstrated that oral Gastrografin is both safe and effective at relieving up to 70% of adhesive small bowel obstructions when administered in the first 24 hours. This is primarily due to its hyper-osmotic nature, as it promotes extra-luminal fluid shift into the bowel lumen, decreasing oedema and improving peristaltic bowel action. When used effectively, Gastrografin may negate the need for surgical intervention where surgery is not possible or not readily available.