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Peroral endoscopic myotomy (POEM) has become widely accepted as a minimally invasive procedure for treatment of achalasia. Here we report a case of achalasia in an 11-month-old girl that was managed by POEM. The patient had been delivered at full term and weighed 2.95kg at birth. Her growth and development were normal until she was 5 months old, when she developed nonprojectile vomiting after feeding. She began to have intermittent cough with fever 3 months later and aspiration pneumonia was suspected. Esophagography showed narrowing of the esophageal gastric junction (EGJ) (●" Fig.1a), that was confirmed by endoscopy. A diagnosis of achalasia was made. Manometry was not performed because of the young age of the patient. At presentation to us the 11-month-old patient weighed only 7.3kg, below the 3rd percentile for her age. POEM was planned. She stayed in hospital for 9 days before the procedure, undergoing nasogastric tube feeding and antibiotic treatment for pneumonia. POEM was then performed by an experienced endoscopist (P.H.Z) (●" Fig.2, ●" Video 1). The standard procedure for adult patients was used, with a standard gastroscope (GIF-Q260J; Olympus, Tokyo, Japan), a hybrid knife (ERBE; Erbe Elektromedizin, Tübingen, Germany) for injection, mucosal dissection, and myotomy, hot biopsy forceps (FD-410R; Olympus) for hemostasis, and clips (HX-610-90; Olympus) for mucosal closure. An initial mucosal incision was done in the 5–6 o’clock position on the posterior esophagus about 5cm above the esophagogastric junction (EGJ) (incisor–cardia distance 25cm). Myotomy was begun 4cm above the EGJ and extended 1cm into the cardia. The infant esophageal muscle was extremely thin and fragile. We applied a method that we call the “push and pull” technique: after an initial partial-thickness cut, the tip of the hybrid knife was inserted into the muscle–serosa plane at 5– 6 o’clock and the full-thickness muscle bundle was lifted towards the esophageal lumen while being electrically dissected (the “push”). At the cardia, because of the limited space, muscle fibers were cut from the luminal side, pulling the scope with a “floor-sweeping” action (the “pull”) [1]. The procedure was uneventful, with the exception of a small mucosal injury at the lower esophagus, which was later clipped. Abdominal bloating occurred and was relieved by needle insertion. The patient had fever and a high white cell count for 2 days after the procedure. She was managed conservatively with meropenem, intravenous immunoglobulin, and intravenous hyperalimentation. Feeding was resumed at postoperative day 5 and the infant was discharged from hospital at postoperative day 13. Endoscopic follow-up at postoperative day 166 showed complete healing of the mucosa (●" Fig.3a), and low grade esophagitis (●" Fig.3b). The endoscope could be passed without resistance. Esophagography showed a slightly dilated esophagus and smooth passage of contrast with mild gastroesophageal reflux (●" Fig.1b). The patient experienced no regurgitation or persistent vomiting following the procedure. There were 2 episodes of upper Fig.1 Esophagography in an 11-month-old girl with achalasia, severe malnutrition, and recurrent pneumonia. a Before peroral endoscopic myotomy (POEM), showing the “bird beak” appearance. b At day 166 postPOEM showing smooth passage of contrast into the stomach. Cases and Techniques Library (CTL) E480

Peroral endoscopic myotomy using the posterior approach in an 11-month-old girl with achalasia, severe malnutrition, and recurrent pneumonia