What is the most appropriate intervention for symmetrical tapering constriction at the level of the gastroesophageal (GE) junction and incomplete lower esophageal sphincter (LES) relaxation with swallowing?

Management of Symmetrical Tapering Constriction at GE Junction with Incomplete LES Relaxation

Per-oral endoscopic myotomy (POEM) is the most appropriate intervention for symmetrical tapering constriction at the gastroesophageal junction and incomplete lower esophageal sphincter relaxation with swallowing, particularly if the condition represents type III achalasia. 1

Diagnostic Considerations

Before proceeding with treatment, a comprehensive diagnostic evaluation is essential to confirm the diagnosis:

• High-resolution manometry (HRM): Gold standard for diagnosing achalasia and determining subtype (I, II, or III)
• Endoscopy: To evaluate for puckered gastroesophageal junction, retained secretions, and rule out pseudoachalasia
• Timed barium esophagram: To document esophageal emptying and structural changes
• Functional luminal impedance planimetry (FLIP): Can confirm impaired EGJ opening through low distensibility index

The findings of symmetrical tapering constriction at the GE junction with incomplete LES relaxation are highly suggestive of achalasia, which requires intervention to relieve the functional outflow obstruction.

Treatment Algorithm Based on Achalasia Subtype

For Type III Achalasia:

• POEM is the preferred first-line treatment 1
  • Allows for longer myotomy extending into the esophageal body
  • Better addresses the spastic contractions characteristic of type III achalasia
  • Superior symptom relief compared to other interventions for this subtype

For Type I and Type II Achalasia:

• Multiple effective options exist:

  1. POEM
  2. Laparoscopic Heller myotomy (LHM) with partial fundoplication
  3. Pneumatic dilation (PD)

• Decision factors include:

  • Patient age and comorbidities
  • Local expertise availability
  • Patient preference regarding invasiveness and risk of reflux
  • Disease characteristics (e.g., esophageal dilation, prior interventions)

Technical Considerations for POEM

If POEM is selected:

• Should be performed by experienced endoscopists in high-volume centers (20-40 procedures needed to achieve competence) 1
• Involves creating a submucosal tunnel and selective myotomy of circular muscle fibers
• Length of myotomy should be tailored to the extent of the motility disorder
• Post-procedure, patients should be monitored for reflux (occurs in up to 58% of patients) 1
• Proton pump inhibitor therapy and surveillance endoscopy may be necessary long-term

Pneumatic Dilation Considerations

If pneumatic dilation is selected:

• Progressive approach starting with 30mm balloon, advancing to 35mm if needed 2, 3
• Success rates of 54% with 30mm balloon and up to 78% with 35mm balloon 2
• When performed by experienced gastroenterologists using fluoroscopic guidance and proper technique, perforation risk is minimal 3
• May require repeat dilations over time
• Five-year remission rates of approximately 54% 2

Laparoscopic Heller Myotomy Considerations

If LHM is selected:

• Should include partial fundoplication to reduce reflux risk
• Excellent long-term outcomes for type I and II achalasia
• Limited ability to extend myotomy far into esophageal body compared to POEM
• Surgical approach may be preferred in patients with large hiatal hernia

Important Caveats

• For EGJOO without confirmed achalasia: Less invasive approaches should be tried first before considering myotomy 1
• Post-POEM reflux: Patients should be advised about high risk of reflux esophagitis (up to 58%) and need for potential long-term PPI therapy 1
• Expertise matters: Outcomes are better when procedures are performed at high-volume centers by experienced operators
• Incomplete LES relaxation without aperistalsis: May not necessarily represent early achalasia and could respond to conservative therapy in some cases 4, 5

The clinical presentation described strongly suggests achalasia, and POEM offers the most versatile approach with excellent outcomes across all achalasia subtypes, with particular advantage in type III achalasia where longer myotomy is beneficial.