Introduction: Achalasia is an esophageal motility disorder that results in the failure of the lower esophageal sphincter (LES) to relax. Moderate to severe forms of the Achalasia can be debilitating due to the patients’ inability to tolerate PO food or drink; often experiencing constant pain or pressure. Peroral endoscopic myotomy (POEM) is a relatively novel endoscopic procedure that has shown more favorable results when compared with other therapeutic modalities in the treatment of achalasia. This case illustrates retrieving an endoscopic cap from a closed submucosal tunnel during a POEM procedure.
Case Description/Methods: A 74-year-old woman with type 3 achalasia underwent a seemingly routine POEM. At the beginning of the procedure, the GE junction was located, and methylene blue was injected to lift the mucosa at the site of the initial mucosectomy. After the mucosectomy was made, the endoscope was used to enter the submucosal tunnel, which was further lengthened by continued lifting and dissection. The submucosal tunnel was then extended to about 1 to 2 cm distal to the gastroesophageal junction (GEJ), and the myotomy was performed that extended into the cardia with no observed complications. After the mucosectomy site was closed with 4 endoclips, it appeared that the cap of the endoscope was missing after the endoscope’s removal from the esophagus. Upon further inspection of the patient's month, bed and floor in the procedure room, the cap was still missing. The endoscope was then reinserted into the patient’s esophagus to continue the search for the lost cap. The intraluminal compartment of the stomach, the esophagus, and the patient’s oropharynx showed no evidence of the cap. Video of the endoscopic procedure was reviewed, and it revealed the presence of bulging mucosa in the distal esophagus along with the absence of the endoscope cap during the clipping of the mucosectomy site. It was determined that the cap was most likely in the submucosal tunnel. After the initial four clips were removed by rat tooth forceps and deposited into the stomach, the scope went into the submucosal tunnel again. The cap was visualized in the submucosal tunnel and removed with the same rat tooth forceps, which was followed by reclosing the mucosectomy site with four more clips. The patient had a successful postoperative course.
Discussion: Review of this case prompts further discussion and research into a more stable cap design for the endoscope, especially for third space endoscopy.
