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PerOral Plication of the Esophagus (POPE): A Novel Approach to Megaesophagus

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posted on 2018-05-24, 17:14 authored by Janani Reisenauer, Wong Kee Song, Louis M., Shanda Blackmon


Esophagectomy is reserved for patients who present with failed treatment for achalasia or megaesophagus. As an alternative, the authors propose a minimally invasive technique to plicate, narrow, and straighten the esophagus. This technique is a peroral plication of the esophagus (POPE) procedure.


The authors describe the case of a 79-year-old woman with long-standing achalasia who was initially treated with a modified Heller esophagomyotomy through a laparotomy in 1977. She developed worsening dysphagia, requiring multiple hospitalizations for aspiration. Because of her comorbidities, she was offered a therapeutic dilation/peroral endoscopic myotomy of the esophagogastric junction.

The POPE procedure includes marking the esophagus in the planned areas to be plicated. A row of full thickness sutures is placed from distal to proximal using an endoscopic suturing device (Apollo Device, Austin, Texas, USA). A running triangular suture pattern alternates from the left lateral wall of the sump to its dependent portion and to the right lateral wall, and is repeated until the conduit or esophagus is narrower, straight, and without a residual sump. The suture anchor/needle is then released and the suturing sequence is tightened with the cinch device. The triangular pattern is repeated until the sump is collapsed.


Postesophagoplasty, the endoscope advanced with ease through the esophagus. The upper esophagram revealed a narrower and straightened esophagus without a residual sump. Improved esophageal emptying was demonstrated one month following the procedure. The patient is tolerating soft food without regurgitation or dysphagia and has no further aspiration events.


In conclusion, endoscopic esophagoplasty is a promising novel technique for achalasia megaesophagus with sump formation in patients who are deemed to be poor surgical candidates for esophagectomy. Long-term follow-up will determine the durability and sustained efficacy of the procedure.

This educational content was originally presented during the STSA 64th Annual Meeting. This content is published with the permission of the STSA. For more information on the STSA and its next Annual Meeting, please click here.


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