Initial intramuscular dissection as a rescue therapy during POM for Echellesia in patients with severe submucosal fibrosis. Peroral endoscopic myotomy is well-established procedure to treat patient with achalesia with high technical success. Severe submucosal fibrosis correlate with long procedure time, more incidence of complication, and even technical failure. Simultaneous submucosal muscle dissection, or BMPOM, are previously described technique to overcome the challenge of submucosal fibrosis. A 50-year-old female with long-standing achalesia for about 25 years. Diagnosed as type 1 achalesia by high-resolution manometry. Her perium swallow showed a marked dilated oesophagus. Her ECART score was 9. Endoscopic evaluation revealed dilated oesophagus with markedly inflamed stiff mucosa. Unsatisfactory submucosal lifting after repeated injection at different site. After mucosal incision, all trials to move to submucosal space was not successful. With the expected thick muscle layer in patient with long-standing achalesia, we decided to create intramuscular tunnel at the entry point as described in the animation, aiming to establish a submucosal tunnel after that. We changed the distal attachment cap to a more tapered one, and start careful partial myotomy near the apex of the mucosal incision. With careful dissection, we were able to create an intramuscular tunnel. Intramuscular tunnel extended for about 3 cm toward the distal oesophagus, and try to move our dissection plane toward the superficial part. Submucosal space was identified by navigation of the scope tip toward the superficial layer, injection of micellin blue confirming the submucosal space. With repeated submucosal injection, expansion of the submucosal space was possible, and continue dissection towards the cardiac and extend our tunnel 3 cm below the cardiac in the gastric side. Carefully check the tunnel from the inside and the mucosa from the outside, and we can see the cardiac became lax, and no mucosal injury can be identified. Start full sickness myotomy from the beginning, from proximal to distal. Continue myotomy in the gastric side for 2 cm. Finally, we close the mucosal incision using multiple hemoclips in a tied fashion. In the post-operative period, patient kept MBO for 2 days, then start clear fluids. No post-procedure complication. The patient showed marked improvement of her symptoms. Her ECART score dropped to 2. Initial intramuscular dissection at level of mucosal incision may serve as salvage option in failure to establish submucosal tunnel due to severe submucosal fibrosis in patient with long-standing akalysia.

rescue therapy

severe submucosal fibrosis

achalasia

peroral endoscopic myotomy

intramuscular dissection