Modified Parural Endoscopic Myotomy Technique using Tailored Bronchoscope in 24 month old child with Achillesia Cardia. No Disclosures POEM for Achillesia Cardia is safe and effective in both children and adults. POEM in adult patients is globally well adapted. However, for Pediatric Achillesia it is limited to few specialized centers as it warrants tailoring of accessories or endoscope in view of narrow cricopharyngeal sphincter and esophageal lumen. Use of Ultraslim transnasal scope with snare tip and systodome has been described for pediatric POEM. However, it limits use of conventional accessories and warrants change of scope for mucosal injection and incision closure. Endoscopy Methods Bronchoscope was tailored using external modifications like insufflation irrigation valve, 3 way stop valve, endotracheal tube refashioned for distal tip attachment and distal connector of intravenous set. Distal connector of intravenous set was detached and was subsequently attached to the CO2 bottle. A 3 way stop valve with long line was attached to the connector. Irrigation tube was additionally attached to the irrigation insufflation valve. This is the overall external assembly. The flow of CO2 was adjusted using the 3 way stop valve. Here we can see the flow being reduced with partial adjustment of the valve. An ultra low flow like CO2 setting was thus created. Free flow of saline irrigation can be appreciated through the instrument channel. A 6.5 mm endotracheal tube was refashioned to create the distal tip attachment over the scope. Right and left scope movements was achieved using torque of the hand and up and down movements was achieved using the wheel. Our case was a 24 month old toddler who was underweight, presented with nasal regurgitation and cough since 14 months. He had recurrent pneumonias and was in a failure to thrive state. Endoscopic barium soil evaluation and manometry evaluation was suggestive of type 2 achalasia cardia. Standard OEM procedure steps were followed. Submucosal injection followed by mucosal injection. Submucosal tunneling was created. Careful submucosal dissection was done. Full thickness myotomy was then performed beyond the G-junction. Alias can be seen well opened up and mucosal incision was closed. Intra post procedure status, capnoperitoneum was drained, frequent blood transfusion was performed. Intra post procedure status, capnoperitoneum was drained, frequent breaks every 5 to 7 minute interval was taken for controlling ETCO2. An experienced vigilant anesthesiologist was a part of our team. Oral diet was resumed after 24 hours. Patient was discharged 48 hours later. A follow up at 1 month interval, barium swallow showed opened up alias with free flow of contrast. And endoscopic evaluation too showed opened up alias with no evidence of food stasis. Healthy granulation tissue was observed at the mucosal incision site. A growth chart at 3 month follow up showed remarkable improvement in weight for height percentile. There was a weight gain of 4 kgs from the baseline weight of 8.2 kgs. Clinical Implications For adult patients with achalagia cardia, standard gastroscope is the best suited scope because of its inherent advantages of irrigation, insufflation, tip deflection in all the directions right, left, up and down and the large instrument channel 2.8 mm which permits all the conventional third space accessories. However, our case was a 24 month old underweight toddler in failure to thrive state which necessitated a narrow calibre scope to be used to navigate across the cricopharyngeal sphincter smoothly and avoid any kind of trauma. Two options for narrow calibre scope were thought of. 1. Ultraslim transnasal scope with outer diameter of 5.7 mm, tip deflection in all directions right, left, up and down inbuilt insufflation but a narrow instrument channel of 2.2 mm. 2. Adult bronchoscope with a wider therapeutic channel of 2.8 mm like any other standard gastroscope but no right, left, tip deflection and no inbuilt irrigation or insufflation. The ultraslim transnasal scope with narrow instrument channel of 2.2 mm is not permissible to standard third space endoscopy accessories which can be detrimental particularly in cases of bleeding wherein bipolar coagulation forceps cannot be introduced for hemostasis. Additionally, change of scopes is required particularly during the first step of submucosal injection and the last step of incision closure as hemoclip applicator cannot be permitted through the narrow channel of the ultraslim scope. On the contrary, our tailored bronchoscope helped us tide over the shortcomings of ultraslim transnasal scope. Irrigation and insufflation was easily provided using some simple external modifications to the scope. The wider instrument channel of 2.8 mm permitted all the standard third space endoscopy accessories including the bipolar coagulation forceps. Change of endoscopes for incision closure or injection was not required. Additionally, bronchoscope is a widely available resource and does not warrant any significant additional learning curve. Conclusion Pediatric POEM using tailored bronchoscope is safe and effective. Tailored bronchoscope is cost effective and easy to adapt tool. It can facilitate widespread utilization of POEM across majority of global centers for pediatric achillesia.

endoscopic myotomy

achalasia cardia

bronchoscope modification

pediatric endoscopy

esophageal treatment