Peroral Endoscopic Myotomy for Refractory Dysphagia in Esophageal Absent Contractility: A Case Report

Esophageal absent contractility is characterized by absent esophageal body contractions despite preserved relaxation of the esophagogastric junction.We describe a patient with severe dysphagia who underwent peroral endoscopic myotomy (POEM).A 55-year-old man presented with progressively worsening dysphagia since childhood, food regurgitation, and heartburn (Eckardt score: 8).Upper gastrointestinal endoscopy showed a megaesophagus with food retention and no resistance to passage through the cardia.A conventional barium swallow also showed a megaesophagus, without the distal "bird's beak" appearance of achalasia.High-resolution manometry showed failed contractions during all 10 supine and five upright swallows, with median integrated relaxation pressures of 13.34 mmHg and 9 mmHg, respectively.A subsequent timed barium esophagram was normal.Twenty-four-hour esophageal pH monitoring performed off proton pump inhibitor therapy showed an acid exposure time of 2%.Dietary measures and a five-day course of metoclopramide did not improve dysphagia.POEM was performed, with a favorable clinical response.At the five-month follow-up, the patient was eating solid food, his Eckardt score was 0, and his weight had increased from 54 to 65 kg.Control manometry at four months showed reduced lower esophageal sphincter resting pressure and integrated relaxation pressures.This case documents short-term improvement in dysphagia and weight after POEM despite persistent absent contractility.Longer follow-up is needed to assess the durability of this response and post-operative reflux.