【视频病例】POEM-SSMD治疗痉挛性食管疾病
Peroral endoscopy myotomy (POEM) is widely known as a treatment modality for achalasia and its use has been expanding to other spastic esophageal motility disorders. POEM with simultaneous submucosal and muscle dissection (POEM-SSMD) has been described for achalasia with severe adhesions in the submucosa of the cardia. We present a challenging case, in which tunneling within the submucosa alone before the myotomy was not possible owing to spastic contractions in the mid-esophagu
经口内镜下肌切开术（POEM）广泛应用于贲门失弛缓症的治疗，其用途已扩展到其他痉挛性食管动力障碍。有研究报道，同时切开黏膜下层与固有肌层POEM（POEM-SSMD）技术可用于治疗贲门失弛缓症伴贲门黏膜下层严重黏连。本次报告的是一例具有挑战性的病例，由于食管中段痉挛性收缩，在进行肌切开术之前无法单独在黏膜下建立隧道。
A 46-year-old woman presented with a long history of dysphagia, with worsening symptoms and chest pain since the previous year. Esophagogastroduodenoscopy with a standard endoscope showed narrowing at the level of the tracheal bifurcation and it was impossible for the scope to traverse the narrowing ([Fig. 1 a]). An endoscopic ultrasonography (EUS) examination showed a thick band of muscle ([Fig. 1 b]). It was possible to pass a nasal endoscope beyond the level of the narrowing and this revealed several diverticula in the esophagus, along with strong contractions. An esophagram showed abnormal esophageal contractions throughout, with a narrowed lumen ([Fig. 2 a]). High resolution manometry was inconclusive because of the difficulty in placement of the catheter.
患者情况：女性，46岁，长期存在吞咽困难的症状，一年前，症状加剧，并伴有胸痛。使用标准内窥镜进行食管胃十二指肠镜检查，结果显示气管分叉处变窄，导致镜身无法穿过（图1a）。超声内镜检查（EUS）显示，存在一条较粗的肌肉带（图1b）。随后使用鼻内窥镜，通过狭窄处，显示食管中存在数个憩室，并伴有强烈收缩。食道造影显示整个食管收缩异常，管腔变窄（图2a）。由于放置导管难度较大，高分辨率测压尚无定论。
The patient was diagnosed with spastic esophageal disorder and underwent POEM ([Video 1]). The mucosal entry was created with a 2-cm longitudinal incision at the 5-o’clock position using a FlushKnife BT (Fujifilm) after submucosal injection. Submucosal dissection was performed to create the submucosal tunnel. As we approached the tight junction with a narrowed tunnel, proceeding with submucosal tunneling alone was not possible. Instead, simultaneous submucosal and muscle dissection had to be performed, which eventually opened up the tunnel ([Fig. 3]). Submucosal tunneling was continued until two penetrating vessels were seen, indicating the distal end of the POEM, and the endoscopic myotomy was completed once the penetrating vessels were reached. A standard endoscope was then passed smoothly through into the stomach. The mucosal entry site was closed with endoclips.
经诊断，该患者患有痉挛性食道疾病，并接受了POEM治疗（[Video 1]）。黏膜下注射后，使用FlushKnife BT（Fujifilm）在5点钟的位置建立一个2cm的纵向切口，创建黏膜入口。进行黏膜下剥离，以形成黏膜下隧道。当我们通过狭窄的隧道接近紧密连接处时，无法单独进行黏膜下隧道建立。因此，必须同时剥离黏膜下层和固有肌层，最终打开了隧道（图3）。继续创建黏膜下隧道，直到显露TPVs，TPVs即为POEM的终点，内镜下肌切开术就完成了。然后将标准内镜顺利通过胃部。使用钛夹封闭隧道入口。
An esophagram on day 1 after the procedure showed an improvement in contrast emptying ([Fig. 2 b]). The patient reported significant improvement in her symptoms 3 months later.
手术后第1天的食管造影显示造影剂排空得到改善（图2b）。该患者在3个月后报告症状明显改善。
Adopting a method of simultaneous submucosal and muscle dissection in a tunnel narrowed because of spastic contractions is feasible to allow successful completion of POEM.
在因痉挛性收缩而变窄的隧道中同时进行黏膜下和肌肉剥离的方法可行，可以成功完成POEM。
Reference：
Thian MY, Tanaka S, Abe H, Sakaguchi H, Ikezawa N, Toyonaga T, Kodoma Y. Peroral endoscopic myotomy with simultaneous submucosal and muscle dissection in spastic esophageal disorder. Endoscopy. 2021 Jan;53(1):E9-E10. doi: 10.1055/a-1167-1043. Epub 2020 May 19. PMID: 32428954.
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