SHIMLA(Himachal Pradesh): A 45-year-old man from Shimla, had been suffering from chronic liver disease (cirrhosis), a condition where the liver shrinks over time, leading to severe complications and the development of large, tortuous blood vessels called esophageal varices at the junction of the food pipe and stomach, with the potential to cause massive bleeding from the mouth.
In addition to cirrhosis, the male patient presented with two other critical conditions affecting the food pipe: achalasia cardia and a large outpouching of the lower food pipe called the oesophagal diverticulum.
Furthermore, the patient had oesophagal varices, a condition common in cirrhosis, where enlarged veins in the food pipe can lead to life-threatening bleeding. Despite undergoing medical treatment for the varices, the patient’s complex condition posed significant treatment challenges.
Dr Shivam Khare, Consultant at the Department of Gastroenterology, Sir Ganga Ram Hospital, explained the difficulties of treating such a case.
“There were two main options for treatment: surgery, which is extremely risky in such cases, or endoscopy. However, the presence of swollen, dilated veins at the gastroesophageal junction made endoscopic treatment even more challenging. This case was particularly complicated because we needed to treat both achalasia cardia and the diverticulum while also ensuring that we avoided bleeding from the prominent, dilated veins at the gastroesophageal junction,” he said.
The medical team, in collaboration with interventional radiologists Dr Arun Gupta, Dr Ajit Yadav, and Dr Raghav Seth, devised a meticulous treatment plan. They first embolized the varices to reduce the risk of bleeding and then proceeded with an endoscopic evaluation, confirming that the varices had been obliterated. The next step was a combined peroral endoscopic myotomy (POEM) procedure, which addressed both achalasia cardia and the diverticulum simultaneously.
Dr Anil Arora, Chairman and Head of the Department of Gastroenterology at Sir Ganga Ram Hospital, explained that the POEM procedure is a minimally invasive endoscopic treatment involving four key steps: mucosal entry, creation of a submucosal tunnel, myotomy (cutting of the oesophagal muscle) of the diverticulum, and myotomy of the lower oesophagal sphincter (LES) for achalasia cardia. During the procedure, special care was taken to coagulate and fulgurate any varices that were encountered, preventing bleeding during the treatment.
Dr Anil Arora stated, “This successful treatment is a remarkable achievement, not only for its complexity but also for the novel approach we employed. The patient, who had previously struggled with swallowing, is now able to consume a normal diet and has a new lease on life within a week after our innovative treatment.”
Dr Shivam Khare added, “This is the world’s first case where two oesophagal diseases —achalasia cardia and oesophagal diverticulum —were treated in a patient with advanced cirrhosis and varices using a single endoscopic procedure.”
The patient, who had previously visited several major medical centres without success, was discharged within three days after the procedure and is now able to swallow seamlessly without any difficulty.
Arora further underlined the importance of the hospital’s advanced diagnostic capabilities. “State-of-the-art diagnostic tools like high-resolution oesophagal manometry and high-definition endoscopes allowed us to diagnose complex disorders like achalasia cardia with ease. To date, we have successfully performed this procedure in over 550 cases, reinforcing our experience in treating such intricate conditions.”
This pioneering procedure was made possible by the unwavering dedication of the entire medical team, including skilled endoscopic assistants, anaesthetists, and the interventional radiology team, whose combined efforts contributed to the success of the case. (ANI)