Novel Per-Oral Cricopharyngotomy for Cricopharyngeal Bar: Feasibility Study With Emphasis on Technical Limitations

Abstract

Per-oral endoscopic cricopharyngotomy (c-POEM) is a treatment for cricopharyngeal dysfunction, specifically cricopharyngeal bars (CPB). C-POEM differs from other endoscopic surgical procedures, such as per-oral endoscopic myotomy (POEM), gastric per-oral endoscopic myotomy (g-POEM), and Zenker per-oral endoscopic myotomy (z-POEM). We report three patients who underwent c-POEM for CPB, their clinical course, and outcomes. We underwent a single institution retrospective chart review of three patients who underwent c-POEM and their immediate postoperative course. These three patients represent all patients who underwent c-POEM. The operating surgeons were experienced endoscopists who regularly performed endoscopic myotomy. The three patients were female, over 50 years old, and presented with dysphagia secondary to the CPB. All three patients had perioperative complications consistent with esophageal leaks requiring prolonged hospital courses and recovery. All three patients had improved but persistent dysphagia up to nine months following the procedure. The results of this small case series exemplify the high rate of complications, specifically postoperative esophageal leak, when performing c-POEM for CPB. Thus, we stress caution and recommend against performing c-POEM for CPB.

Peroral endoscopic myotomy for the management of symptomatic cricopharyngeal bar (C-POEM): a case series and video demonstration

“…Therefore, although balloon dilatation is a reasonable alternative, successive dilatations could lead to submucosal fibrosis, making the subsequent myotomy, if required, more difficult. We recognize concerns about C-POEM recently raised by Pittala et al [ 13 ], who reported 3 cases that all developed an esophageal leak post-endoscopy. They determined that this was due to difficulty working within the hypopharynx and conducting the initial mucosotomy, alongside other technical aspects.…”

“…We would agree that the most challenging aspect of the procedure is the mucosotomy, which sets the precedent for a successful procedure. It is interesting to see that Pittala et al [ 13 ] started their mucosotomy 2 cm above the bar, whereas we would argue that the mucosotomy should take place directly over the bar to ensure orientation and enable tunnelling down into the esophagus, rather than inadvertently into the pharynx. Use of a conical transparent distal attachment can help within the tight space of the hypopharynx.…”

Underwater cricopharyngeal peroral endoscopic myotomy

“…Peroral endoscopic myotomy (POEM) is a well-established third-space endoscopic technique that can be technically challenging when used to treat a cricopharyngeal bar, even for experienced operators, due to the limited working space in the hypopharynx and upper esophageal sphincter 1 2 . Here we propose the use of saline immersion to improve the technical success rate of the procedure.…”

Precision Endoscopy in Peroral Myotomies for Motility Disorders of the Upper Gastrointestinal Tract: Current Insights and Prospective Avenues—A Comprehensive Review

“…It is an endoscopic technique for treating cricopharyngeal bar [166,167] or oropharyngeal dysphagia associated with Parkinson's disease [168]. The procedure involves a submucosal injection and a mucosal incision performed approximately 2 cm above the cricopharyngeal muscle.…”