Clinical outcomes and safety of high-resolution manometry guided superficial partial circular muscle myotomy in per-oral endoscopic myotomy for Jackhammer esophagus: Two cases report

Abstract

Background: Jack hammer esophagus is a relatively rare disease and to date, there is no dramatic treatment option. Recently, conventional per-oral endoscopic myotomy (POEM) have expanded their area into Jackhammer esophagus. However, several complications such as post procedure motility disorders (e.g., passage disturbance) are issues after POEM. To overcome these issues, we here introduced high-resolution manometry (HRM)-guided superficial partial circular muscle myotomy, which involves cutting only the superficial layer of the esophageal circular muscle.

Case summary: We report two cases of patients with Jackhammer esophagus who were treated with HRM-guided extremely superficial partial circular muscle myotomy during POEM. Case 1 was a 53-year-old female with medication-refractory odynophagia and case 2 was a 47-year-old man who presented with chest pain. They were diagnosed with Jackhammer esophagus using HRM, and the hypercontractile segments of the esophagus were identified. HRM-guided extremely superficial partial circular muscle myotomy was performed while preserving the lower esophageal sphincter. Therefore, the circular and longitudinal muscle layers are preserved but hypercontractile movements are reduced, even after POEM. Patients' clinical symptoms dramatically improved right after POEM, and 6-mo follow-up HRM revealed completely resolved status. During a 1-year follow-up period, patients were still in good health and remained symptom free.

Conclusion: HRM-guided superficial partial circular muscle myotomy may be a promising alternative to conventional POEM for treating Jackhammer esophagus with improved efficacy.

Keywords: Case report; Hypercontractile; Jackhammer esophagus; Partial circular muscle myotomy.

Figure 1

The examination of 53-year-old woman conducted before superficial circular muscle per-oral esophageal myotomy. A: Pre-treatment high-resolution esophageal manometry (HRM) image depicted a jackhammer esophagus patient with distal contractile index over 8000 mmHg.s.cm; B-D: Barium radiography showed spasmodic contraction of the distal esophagus and a narrowing of the esophageal cavity (C) Post-treatment HRM revealed distal contractile integral of 980 mmHg.s.cm (D) Post-treatment esophagogram showed improved.

Figure 2

The examination of 47-year-old man conducted before superficial circular muscle per-oral esophageal myotomy. A: Pre-treatment high-resolution manometry (HRM) showed high-amplitude distal esophageal contractions with a distal contractile integral (DCI) value > 8000 mmHg.s.cm for 8 of a total of 10 swallows and the highest DCI value was 13553 mmHg.s.cm; B-D: Pre-treatment esophagography showed spasmodic contraction of the distal esophagus (C) Post-treatment HRM revealed within normal range of DCI (D) Post-treatment esophagogram showed improved function of passage of esoaphagus.

Figure 3

Procedures of high-resolution manometry guided superficial partial circular muscle myotomy. A: We first detect the hypercontractile lesion through high-resolution manometry (HRM), and in this patients’ case, HRM showed high-amplitude distal esophageal contractions located 25-38 cm from the incisors according to the distance gauge of the pressure measuring tubes. B: Therefore, we performed superficial partial circular muscle myotomy of the esophageal muscle on the right side, (B) Superficial partial circular muscle myotomy during POEM. Remnant circular muscle.