Patient Case Presentation: Refractory GERD and Dysphagia Post-POEM and TIF

28 Apr 2026 17:00 18:30
São Paulo
Rubens Sallum Host
Camila de Câmara Panelist
Valter Nilton Felix Panelist

Patient Profile & History

  • Patient: 63-year-old male

  • Diagnosis: Type I Achalasia

  • Initial Presentation: Daily dysphagia and regurgitation refractory to endoscopic dilation.

Clinical Timeline & Disease Progression

  • October 2016 — Primary Procedure: Underwent Per-Oral Endoscopic Myotomy (POEM). Postoperatively developed severe heartburn and retrosternal pain refractory to proton pump inhibitors (PPIs).

  • 2021 (5 Years Post-POEM) — Secondary Procedure: Endoscopic fundoplication using the Esophyx Z device (3 stitches at 11 o'clock; 2 stitches at 5, 7, and 1 o'clock), achieving a partial fundoplication with good intraoperative appearance.

  • Post-TIF Follow-Up: Persistent heartburn, regurgitation, retrosternal pain, and low-solid dysphagia. Serial follow-ups revealed progression to Los Angeles Grade D esophagitis with esophageal ulcers.

Diagnostic Workup

  • Endoscopy: Gastrogastric suture site with formation of a "neochamber"; severe Los Angeles Grade D esophagitis with esophageal ulcerations.

  • Barium Contrast Swallow: Marked contrast retention and delayed esophageal clearance.

  • High-Resolution Manometry (HRM): Confirmed Type I achalasia with absent esophageal body contractility, incomplete lower esophageal sphincter (LES) relaxation, and EGJ hypotonia.

Surgical Revision & Postoperative Outcome

Following multidisciplinary review, the patient was indicated for medical optimization and laparoscopic revision surgery.

  • Intraoperative Findings: Dense hiatal adhesions from prior Esophyx Z device placement.

  • Surgical Steps: Careful adhesiolysis, correction/dismantling of the endoscopic neochamber, hiatal cruroplasty with interrupted non-absorbable sutures, and an anterior 180° Dor fundoplication.

  • Postoperative Course: Discharged on Postoperative Day 1 on a creamy diet.

  • Outpatient Follow-Up (2 Weeks): Asymptomatic with no reported complaints, good dietary tolerance, complete absence of dysphagia, and significant resolution of reflux symptoms (Weight: 73 kg, BMI: 22 kg/m²).

Panel Members

Rubens AA Sallum | Gustavo G Quintas | Arthur Y Arabi | Edno Tales Bianchi | Camila de Câmara | Ivan Cecconello | Alexandra Cirlinas | André Fonseca Duarte | Valter N Félix | Fauze Maluf Filho | Ary Nasi | Rodrigo Nicida | Rodrigo José de Oliveira | Ulysses Ribeiro Junior | Júlio Mariano da Rocha | Francisco CBC Seguro | Sérgio Szachnowicz | Marcos Tacconi

Topics for Discussion

  1. What is the best anti-reflux strategy for recurrence of symptoms after endoscopic or surgical POEM?

  2. Endoscopic anti-reflux devices: where are we now regarding results and feasibility?

  3. In a patient with Type I achalasia, is there a difference in the treatment approach in comparison with Type II achalasia? What are your preferences?