Tsunokake Junichi, Taniyama Yusuke, Fujishima Fumiyoshi, Sato Chiaki, Okamoto Hiroshi, Fukutomi Toshiaki, Ozawa Yohei, Ujiie Naoto, Koseki Ken, Gokon Yusuke, Horiuchi Makoto, Akaishi Ryujiro, Yamauchi Takuro, Unno Michiaki, Kamei Takashi
Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan.
Department of Pathology, Tohoku University Hospital, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan.
Surg Case Rep. 2021 Aug 19;7(1):186. doi: 10.1186/s40792-021-01270-z.
Esophageal achalasia causes dysphagia following impaired relaxation of the lower esophageal sphincter due to the degeneration of Auerbach's plexus in the esophageal smooth muscle. Recently, peroral endoscopic myotomy (POEM) has become one of the preferred treatment options for esophageal achalasia. However, pathomorphological changes after POEM have not been well examined.
A 65-year-old man with a history of POEM for esophageal achalasia was diagnosed with clinical stage II (cT2-N0-M0) thoracic esophageal squamous cell carcinoma and was consequently treated with neoadjuvant chemotherapy followed by thoracoscopic esophagectomy. Intraoperatively, the esophagus appeared dilated, reflecting esophageal achalasia; however, fairly slight fibrous adhesions were observed between the esophagus and the pericardial surface despite previously performed POEM via an anterior incision. Histopathological examination revealed esophageal wall thickening, edema, and fibrosis extending from the lamina propria to the submucosa. Besides, the majority of the inner layer and some proportion of the outer layer of the muscularis propria were found to be missing or atrophic at the esophagogastric junction (EGJ). No ganglion cells could be detected at the Auerbach's plexus.
The previous history of POEM did not affect circumferential mediastinal periesophageal dissection during thoracoscopic esophagectomy. Nevertheless, a large proportion of the inner layer of the muscularis propria at the EGJ level seemed to have become lost or atrophic because of the POEM procedure.
食管贲门失弛缓症是由于食管平滑肌中奥尔巴赫神经丛退变导致食管下括约肌松弛受损而引起吞咽困难。近年来，经口内镜下肌切开术（POEM）已成为食管贲门失弛缓症的首选治疗方法之一。然而，POEM术后的病理形态学变化尚未得到充分研究。
一名65岁男性，有POEM治疗食管贲门失弛缓症病史，被诊断为临床II期（cT2-N0-M0）胸段食管鳞状细胞癌，因此接受了新辅助化疗，随后进行了胸腔镜食管切除术。术中，食管呈扩张状态，提示食管贲门失弛缓症；然而，尽管之前经前路切口进行了POEM手术，但在食管与心包表面之间观察到相当轻微的纤维粘连。组织病理学检查显示食管壁增厚、水肿，纤维化从固有层延伸至黏膜下层。此外，在食管胃交界（EGJ）处，大部分固有肌层内层和部分外层缺失或萎缩。在奥尔巴赫神经丛未检测到神经节细胞。
既往POEM手术史不影响胸腔镜食管切除术中食管周围纵隔的环形解剖。然而，由于POEM手术，EGJ水平的固有肌层内层似乎大部分已经缺失或萎缩。
