peroral plication of the esophagus pope, and sigmoid-type achalasia, considerations and techniques for an organ-sparing approach. End-stage achalasia can result in megaesophagus with dilation and sigmoid-type appearance. A subformation promotes pulling of oral secretions and food and may produce post-reagitation, retrosternal pain, pulmonary aspiration, and mucosal stasis and ulceration. Lower esophageal sphincter directed therapy, such as Heller myotomy and peroral endoscopic myotomy, can still be offered, albeit with reduced efficacy and higher complication rates. Esophagectomy remains a salvage option with high morbidity. Sigmoid-type achalasia can be further categorized into sigmoid-type 1 and sigmoid-type 2, according to the degree of tortuosity of the lumen. In S1, the esophagus is significantly dilated and tortuous, but imaging will reveal a single lumen with a downward direction. In contrast, S2 represents a more advanced form where the esophagus becomes very dilated, severely tortuous, forming U-turns in a proximal direction. Imaging may reveal a double lumen in some slices, reflecting the extreme anatomical distortion found in S2. The degree of esophageal dilation can also be classified into three groups, grade 1 under 3.5 centimeters, grade 2, 3.6 to 6 centimeters, and grade 3, greater than 6 centimeters. Peroral plication of the esophagus poke is a novel minimally invasive endoscopic alternative to esophagectomy utilized in cases of sigmoid-type achalasia. It can be offered in advanced achalasia after successful resolution, staphylgastric junction outlet obstruction via myotomy. A 56-year-old male with a history of type 1 achalasia status post-laparoscopic keloid myotomy with 2p fundoplication, along with a history of T2 colorectal cancer treated with no anterior resection, followed by recurrence at the anastomosis one year later, requiring repeat resection without adjuvant therapy, sent to clinic with persistently symptomatic achalasia with an effort score of six. Chromal CT images demonstrated grade 3 dilation with S1 morphology and large amounts of retained material. The patient was scheduled for further evaluation with upper endoscopy. Despite adhering to a one-week liquid diet, the procedure revealed a large amount of food remnant in the esophagus, necessitating cautious induction of anesthesia to minimize aspiration risk. Food clearance was achieved with a lavage, suction, and the use of an over tube to ensure safe progression to further intervention. Embedded splenometry demonstrated normal esophagogastric junction opening, suggesting adequate prior myotomy. Given evidence of adequate myotomy, esophagectomy was offered, but the patient declined. After a multidisciplinary discussion with shared decision-making, the patient was offered TOG. A two-stage approach was employed due to the significant amount of food remnant observed. The patient was instructed to adhere to a liquid diet for one week prior to the procedure. During the first stage, EGD revealed a large amount of retained food, which was successfully cleared with lavage and suction. The patient was discharged on a clear liquid diet and returned three days later for the second stage, the PO procedure. The PO procedure is performed under general anesthesia using an endoscopic suturing system that requires a dual-channel therapeutic endoscope. The system utilizes a tissue helix for precise tissue capture and two O-polypropylene sutures. This illustration demonstrates the key objectives of the procedure, which is reducing the subregion and straightening the esophagus through strategic placation. As shown, placations are placed through coagulation and minimize the pooling of food and secretions in the distal esophagus. Endoscopic methods. An argon plasma coagulation probe was first used to mark the anterior and posterior extents of suturing and placation. Care was taken to avoid excessive luminal narrowing while ensuring effective placation. Our efforts were concentrated in the region of the distal sump where pooling was most pronounced. Drawing inspiration from endoscopic bariatric techniques, we incorporated APC bridges to enhance the durability of placations by inducing fibrosis in the esophageal tissue. Sutures were placed using U and I patterns, beginning anteriorly and progressing circumferentially. Special attention was paid when utilizing the tissue helix to minimize the risk of injury to adjacent structures. The helix was carefully drilled into the submucosa, ensuring precise tissue capture without excessive tension on the surrounding areas. Once the suture line was completed, it was cinched, anchored, and cut to secure the plication. A total of four placations were performed in a distal to proximal manner. After the subregion had been eliminated, the endoscope was reintroduced to confirm lumen patency and ensure no complications had occurred. Water-soluble esophagram post-op day one confirmed no weak. The patient was discharged on a full liquid diet for two weeks. The patient reported improvement in symptoms following the procedure. Two months post-POPE, EGD revealed persistent food retention as seen in figure 10. A careful evacuation of the retained material followed with evaluation demonstrated significant improvement in luminal dilation and reduced sigmoid angulation as shown in figure 11. Dramatic dilation was performed with balloon inflation to 30 mm. This was followed by a repeat POPE procedure to further reduce residual pooling and optimize esophageal function. The patient underwent redo POPE to address the remnant distal sum. The patient was discharged home on a liquid diet for four weeks. He is due for follow-up endoscopy in three months. Patients within stage A palasia that have undergone myotomy and assessment of LES to confirm adequacy of myotomy can be considered for the POPE procedure. Esophagram or scintigraphy can be helpful to evaluate if the cell is the culprit of ongoing symptoms. Multidisciplinary discussion is recommended. Careful discussion of risk is necessary. Orientation during endoscopy is critical to ensuring successful procedure. Proper positioning and pooling of fluids can assist in maintaining proper visualization. Careful attention must be paid to the position of vital surrounding structures throughout the procedure. It is essential to avoid drilling the tissue helix beyond the submucosa as injuries to adjacent structures could result in life-threatening complications. Finally, the optimal number of placations, bites per placation, and seizure patterns remain areas of ongoing investigation. POPE represents a novel, minimally invasive endoscopic alternative for managing sigmoid type A palasia in patients with adequate prior myotomy. While long-term data is currently lacking, the procedure is safe, repeatable, and offers flexibility in symptom management. Repeat interventions may be feasible and necessary to maintain long-term efficacy.

POPE

sigmoid-type achalasia

endoscopic suturing

minimally invasive

esophageal dilation