Combination of concurrent endoscopic submucosal dissection and modified peroral endoscopic myotomy for an achalasia patient with synchronous early esophageal neoplasms

Figure 1 Chest computed tomography examination showed that the esophageal cavity was obviously expanded (A-C); large amount of fluid retention was seen in the lumen (D). The cardiac muscle layer was significantly thickened.

Figure 2 Cardia was tightly closed and the resistance. A, B: Lesion at 24 cm from the incisor and Narrow-band imaging (NBI) with magnification revealed type IV intra-epithelial papillary capillary loops (IPCLs) according to Inoue’s classification; C, D: Another lesion at 32 cm, IPCLs were type V1; E, F: The third lesion in 34 cm IPCLs were type IV-V; G-I: The esophageal lumen below 30 cm was distorted and enlarged. The cardia was tightly closed; the resistance is significant.

Figure 3 Peroral endoscopic myotomy procedure. A: A 2-cm longitudinal incision was made into the mucosa after injection of natural saline with indigo carmine and epinephrine; B: A submucosal tunnel from the esophagus to the gastric cardia was created using a Dual knife; C: The submucosal tunnel was completed; D and E: The muscularis propria were dissected and the myotomy was completed using a Dual knife; F: The entry site in contralateral side of Endoscopic submucosal dissection wound was closed using hemostatic clips.

Figure 4 Endoscopic submucosal dissection procedure and pathological examination. A-D: Marking around the lesion using Dual knife; submucosal injection of 10 mL saline with 0.3% indigo carmine and 1:100000 epinephrine; cutting open the mucosa; the submucosa was stripped and the lesion was completely resected; E, F: Pathological examination of the resected specimen revealed high-grade intraepithelial neoplasia with a component of scattered low-grade intraepithelial neoplasia. Both of the lateral and vertical margins were negative of tumor.