【The story of coordinator】 POEM treatment for esophageal achalasia and problems at the esophageal-gastric junction　The patient is thrilled that the POEM has resolved the pain of not being able to eat a meal satisfactorily

The patient was not feeling well after surgery for reflux esophagitis and became mentally unstable

Surgery to tighten the junction of stomach and esophagus performed in home country of the patient

This patient, who lives in an Asian region near Japan, has been suffering from a loosening of the junction between the esophagus and stomach for many years, what is called reflux esophagitis, inducing food and stomach acid to flow back into the esophagus, and the strong acid causes inflammation in the esophagus. For this treatment, the patient underwent “Nissen fundoplication” in his home country. This is a laparoscopic surgery in which the upper part of the stomach is wrapped around the back of the esophagus and sutures are placed at that point to tighten the junction between the stomach and esophagus.

Request to return to pre-surgery condition

However, after the surgery, the patient’s symptoms became even worse than before, and he felt heaviness after meals, felt a tingling pain in his chest, felt nauseous, and had stomach pain that lasted for about 2 to 3 hours. During that time, he was unable to lead a normal daily life. He was unable to eat much, could not sleep at night, and became mentally unstable. Thinking that the fundoplication surgery may not have been successful, he requested treatment in Japan to return to his pre-surgery condition. Though the medical information provided was a pre-surgery image, the gastroenterologist, who was watching this, conducted an online examination and thought that the junction between the esophagus and stomach had probably been tightened too much during the surgery for reflux esophagitis, and scheduled surgery to moderately loosen the part that had been tightened too much by laparoscopy.

It turned out that the symptom was due to another cause

However, after arriving in Japan, an endoscopy revealed that the junction of the esophagus and stomach where the surgery was performed was not too narrow and there was no problem. The exit of the stomach pouch is an area called the pylorus, which has a special muscle called the pyloric sphincter that moves the contents of the stomach into the small intestine. The stomach also has the vagus nerve, which branches out and heads toward the pylorus, and this vagus nerve has the function of transmitting signals to the digestive system and controlling functions such as gastric motility. The doctor’s opinion is that the vagus nerve has been paralyzed by the previous surgery, making it difficult for food to pass from the stomach to the intestines, which is the reason why the patient always feels sick after eating.

Symptom completely improved after G-POEM surgery

Applying POEM developed by a Japanese doctor to the pylorus of the stomach

The doctor proposed a surgery called G-POEM to improve this condition. This is a surgical procedure performed using an endoscope on the muscular layer of the stomach, especially for conditions in which the muscles at the outlet (pyloric region) of the stomach contract excessively, preventing the normal movement of food. POEM is a surgery performed to treat esophageal achalasia, where the junction between the esophagus and stomach fails to relax properly, causing food to remain in the esophagus instead of being delivered to the stomach. This is a technique that was developed by Dr. Haruhiro Inoue, Director of Digestive Organ Center, Showa University Toyosu Hospital, ahead of the rest of the world. G-POEM is a surgery that performs on the pylorus. It was Professor Inoue that EAJ consulted with regarding this case.

Performing G-POEM

How was the actual surgery performed? First, the endoscope is inserted through the mouth. A small incision is made between the mucosa and muscle layer in front of the pylorus, and the endoscope is entered through the submucosa. At this place, an expansion balloon attached to the tip of the endoscope is used to expand the submucosal space and secure a working space. Then cut the pyloric sphincter. If cut correctly, you will see a ring-shaped cut surface about 1cm in diameter. The amputation breaks the continuity of the muscle, which reduces the muscle’s ability to contract due to excessive tension, allowing the pyloric ring to naturally relax, enabling food to move out of the stomach smoothly. After the surgery, the first incision is closed with clips and the balloon is removed.

Joy of being able to eat normally after successful surgery

After the surgery, the patient was very happy, saying that he was able to eat delicious meals without feeling any heaviness or pain after meals, and was able to eat his favorite pickled vegetables. He is now able to sleep better and is feeling much better. During his treatment in his home country, he met people suffering from similar symptoms, and he said he would like to introduce Dr. Inoue to everyone.

High track record for esophageal achalasia

G-POEM is a surgical procedure that was originally developed and established for the purpose of loosening the junction between the esophagus and stomach for achalasia. Patients suffering from the esophagus achalasia come to Dr. Inoue from the United States and elsewhere. There arises a natural flow of patients who have undergone surgery referring other patients to Dr. Inoue, and so far EAJ has provided coordination for nearly 10 patients. If you are a patient suffering from esophageal achalasia, please contact EAJ.