PMC4700856_01
The endoscopic findings before and during peroral endoscopic myotomy (POEM): (A) The endoscopic findings before POEM. A slightly depressed, reddish lesion was visible in the mid-thoracic esophagus. (B) The endoscopic findings during POEM. There is severe fibrosis in the submucosal space. (C) The cracked part of the muscles. (D,E) Myotomy from extraesophageal space
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F1
Histological diagnosis of the biopsy specimen prior to POEM was esophagitis (non-cancerous part) (Fig. 1A). During the POEM procedure, it was very difficult to create the submucosal tunnel because the mucosa adhered to the muscles (Fig. 1B). Therefore, we inserted an endoscope into the extraesophageal space through a tear in the musculature (Fig. 1C). Triangle Tip knife to prevent mucosal damage outside of the esophagus (Fig. 1D). The total length of myotomy was 8 cm (the gastric side was 1 cm).
The histopathological findings of the resected specimen: (A) The macroscopic appearance of the resected specimen. The area occupied by the intramucosal carcinoma was ill-defined in the mid-thoracic esophagus. The scar was located in the lower esophagus. The red and green lines indicate the intramucosal squamous cell carcinoma and scar, respectively. (B) The histologic appearance of the muscularis propria divided by the peroral endoscopic myotomy (POEM) procedure (hematoxylin and eosin staining). (C) Desmin immunostaining demonstrates the muscularis propria, partially removed by the POEM procedure. The area of myotomy by POEM is between the arrows. (D) Masson-trichrome staining demonstrates the muscularis propria, replaced with dense fibrous tissue. The area of myotomy by POEM is demarcated between the arrows
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F2
There were two main histological findings: first, intramucosal cancer; and second, the muscle tissue that had been divided by the POEM procedure was replaced with fibrotic tissue (Fig. 2 A,B,C,D).