To minimize invasion - Is it possible to treat a patient's early esophageal cancer and achalasia within one operation?

Background and aim: Patients with achalasia face an increased risk of dysplasia and squamous cell carcinoma due to chronic inflammation. We demonstrated the feasibility of performing endoscopic submucosal dissection (ESD) and well-designed peroral endoscopic myotomy (POEM) within a single operation, aiming to reduce trauma and enhance recovery.

Methods: A 65-year-old male with progressive dysphagia was diagnosed with type II achalasia and suspected esophageal lesions. Our treatment plan involved addressing both achalasia and the lesions using POEM and ESD during one operation. POEM was initiated with a 2-cm longitudinal incision at 5 o'clock, establishing a submucosal tunnel from 32 cm from the incisors to 2 cm distal to the gastroesophageal junction. A 4 cm myotomy of the esophageal segment was performed, extending 2 cm into the proximal stomach. Subsequently, ESD was conducted on the suspicious lesion in the mid-esophagus.

Results: En-bloc resection was achieved and histology revealed high-grade dysplasia with horizontal margin showed low-grade dysplasia. Follow-up assessments demonstrated decreased Eckardt's scores and no evidence of recurrence.

Conclusions: By carefully planning the direction and length of the myotomy, we successfully managed POEM and ESD in a single operation. Individualized modifications to endoscopic procedures are crucial for achieving minimally invasive and cost-effective treatment for patients presenting with achalasia combined with esophageal early cancer.