P1.015. A Potential Option for Blown-Out Myotomy After Peroral Endoscopic Myotomy

Abstract

Abstract Topic Benign Disease: Esophageal Function and Motility Case Submission A 52 year old female with an extensive medical history including left lower limb dystrophy and a complex pain problem for which she is wheelchair bound, received several neurostimulators and had a high morphine consumption (Fentanyl patch 100μg/h). She presented with reflux and dysphagia complaints in 2018, after which she was diagnosed with type 3 achalasia (potentially opioid-induced) based on high-resolution (HR) esophageal manometry. She underwent a peroral endoscopic myotomy (POEM) procedure and experienced only partial alleviation of her complaints thereafter. In 2021, her complaints of dysphagia were worsening again. Endoscopy showed a dilated distal esophagus with fungal esophagitis but easy passage to the stomach. Barium swallow showed a left-sided diverticulum of ±35mm and HR manometry indicated an IRP4 of 42 mmHg as well as swallows that were never followed by normal peristaltic contractions; only fragments of distal peristalsis. EndoFLIP at 32-28cm showed a distensibility of 7.1mm2/mmHg, diameter 15mm, and balloon pressure of 24 mmHg at 60mL volume of the balloon and the presence of a high pressure zone at 28 to 22 cm, with evidence of spasticity, for which the high pressure zone was infiltrated with botulinum toxin 100 IU. At that time, morphine consumption was still Fentanyl patch 50μg/h. Complaints did not improve afterwards, on the contrary she experienced more dysphagia and regurgitations after every meal, lost 10 kg of weight and suffered from recurrent aspiration pneumonias in the following years. In 2025, the treatment team succeeded in tapering off morphine consumption to 10mg oxycodone. Nevertheless, she lost an additional 5kg of weight and sufferede from another aspiration pneumonia. HR Manometry showed an IRP4 of 9mmHg and ineffective motility without peristaltic recuperation by provocation. Barium swallow showed the known left-sided “diverticulum” or blow-out of the myotomy (fig 1A). After multidisciplinary discussion, it was decided to opt for a transthoracic plicature of the blow-out of the myotomy through a left-sided robotic approach: two rows of slowly resorbable continuous sutures were used, guided by a peroperoperative endoscopic view. Postoperative barium swallow is shown in Fig 1B. The patient was discharged at POD 5 without complications. At 4 weeks postoperatively, she had no regurgitations anymore and is transitioning form liquid tot solid diet. Further follow up and manometry are planned.