Tandem peroral endoscopic myotomy and transoral incisionless fundoplication, a strategy to reduce reflux after peroral endoscopic myotomy. The authors for this video are Nicholas A. Herter, David A. Greenwald, Christopher J. DeMeo, Satish Nagula, Rebecca E. Dixon, and Nikhil A. Kumpta. These are our disclosures. The patient is a 41-year-old male with severely symptomatic type 2 achillesia. He endorses dysphagia to both solids and liquids for three years with a 5-7 kg weight loss. He induces emesis prior to sleep to avoid waking with severe regurgitation. He has an ACHERT score of 11 out of 12, indicating severe symptoms. Findings on endoscopy, esophogram, and manometry support the diagnosis. The peroral endoscopic myotomy is performed by making a mucosotomy 10 cm proximal to the GE junction, creating a submucosal tunnel extending 2 cm beyond the GE junction, performing a full thickness myotomy, starting 2 cm distal to the mucosotomy, ending 2 cm beyond the GE junction, and closing the mucosotomy with endoscopic suturing. The transoral incisionless fundoplication is performed by inserting the fundoplication device into the stomach and retroflexing at the GE junction, then using a combination of the tissue helix and endoscopic suction to pull the GE junction tissue into the device, and manipulating the device and deploying multiple H-shaped anchors to create a 270-degree tissue wrap and lengthen the GE junction flat valve to 2 cm. Peroral endoscopic myotomy. First, the endoscope fitted with a clear, tapered cap is used to examine the GE junction to establish a baseline level of resistance. A submucosal injection of saline and methylene blue is made in a posterior orientation to begin the mucosotomy. The mucosotomy is performed with a multipurpose electrosurgical knife. The mucosotomy is extended laterally, and the cap is used to enter the submucosal space. A submucosal tunnel is created, and the electrosurgical knife is used to dissect and extend the tunnel to the GE junction and 2 cm beyond into the cardia of the stomach. Tunneling is performed in standard fashion, using injection of saline with methylene blue and electrosurgical cutting current. Larger vessels identified during dissection are prophylactically cauterized with monopolar coagulation forceps. Tunnel dissection of the submucosa is complete, extending 2 cm into the cardia of the stomach. The myotomy is started 2 cm distal to the mucosotomy site. The lower esophageal sphincter is dissected and the myotomy is continued 2 cm into the cardia. After the myotomy is complete, the tunnel is inspected to ensure full-thickness myotomy and no damage to the mucosal layer, and the GE junction is inspected with improvement of resistance. Transoral incisionless fundoplication The fundoplication device is inserted into the stomach and placed into position, viewing the GE junction in retroflexion. The tissue helix is used to grasp the tissue. The stomach is desufflated. Tissue is pulled into the tissue mold while the device is rotated to create a wrap. The device is fired with two fasteners placed on each fire. This process is repeated for six fasteners at the 1 o'clock position and six fasteners at the 11 o'clock position. Additional supportive fasteners are added at the 5 o'clock and 7 o'clock positions to lengthen the flap for a total of 28 fasteners. The final result, as viewed here, is a 270 degree wrap with an approximately 2 centimeter length. Endoscopic suturing The POEM mucosotomy site is closed using the endoscopic suturing device, with a single running suture performing four bites of tissue, including the distal and proximal ends of the mucosotomy. After the final bite, the suture anchor is dropped. A cinch device is used to tighten and secure the suture. On final inspection, the GE junction flat valve is significantly augmented post-tiff, the esophageal mucosa is intact post-poem, and the mucosotomy is completely closed. After the procedure, the patient was admitted for observation. On post-operative day 1, an esophagram confirmed that there was no leak and the patient was discharged home. On follow-up, the patient noted improvement in symptoms with no emesis or nocturnal regurgitation he gained weight, his Eckert score improved, and he noted no reflux symptoms and he was not taking a proton pump inhibitor. The clinical implications of this case are that peroral endoscopic myotomy is an effective treatment for achalasia, although reflux is a commonly cited complaint after poem. Performing a transoral incisionless fundiplication immediately following poem may help prevent this reflux. In conclusion, tandem peroral endoscopic myotomy and transoral incisionless fundiplication in a single session is a strategy to prevent reflux after poem, especially in young patients. However, further study is needed to determine the long-term safety and efficacy of this technique.

type 2 achalasia

POEM

TIF

reflux prevention

symptom improvement