“The challenge for us was to do this novel procedure in such a low weight child of this young age of 6 years (one of the youngest in India to the best of our knowledge) and also low weight of the child 11 Kg (lowest weight to the best of our knowledge in India) as there was substantial risk of infection, aspiration and respiratory problem in this emaciated underweight child. There was also going to be limitations of the use of adult endoscopic equipment and accessories used in POEM procedure to be used in a small child.” …….. Prof. (Dr.) Anil Arora

Recently the Department of Gastroenterology at Sir Ganga Ram Hospital received a 6 year old girl who was not able to swallow food for almost 3 years.

She had repeated vomitings and regurgitation of food from mouth and nose which resulted in her marked weight loss.

Prof. (Dr.) Anil Arora, Chairman and Head of the Department of Gastroenterology at Sir Ganga Ram Hospital, “When she came to us she was very thin, emaciated and marasmic (protein malnutrition) and weighed 8-10 Kgs lower than the normal weight of her corresponding peers. We diagnosed her to be suffering from Achalasia Cardia (swallowing disorder) after evaluating her with endoscopy, barium swallow (Figure 1) followed by high resolution esophageal manometry.”

Till recently the established treatment of Achalasia Cardia in children was surgical intervention but in her case we decided to perform a relatively new endoscopic procedure in this child called POEM (Per Oral Endoscopic Myotomy).

Prof. (Dr.) Anil Arora further added, “The challenge for us was to do this novel procedure in such a low weight child of this young age of 6 years (one of the youngest in India to the best of our knowledge) and also low weight of the child 11 Kg (lowest weight to the best of our knowledge in India) as there was substantial risk of infection, aspiration and respiratory problem in this emaciated underweight child. There was also going to be limitations of the use of adult endoscopic equipment and accessories used in POEM procedure to be used in a small child.”

According to Dr. Shivam Khare, Consultant, Department of Gastroenterology, Sir Ganga Ram Hospital, “The POEM procedure consists of four steps: (A) Mucosal entry (B) Creation of submucosal tunnel (C) Initiation and Extension of Myotomy and (D) Closure of Mucosal Entry”.
The above four steps mean cutting the internal lining of the food pipe, creating a tunnel between the muscle layers and the inside lining of the food pipe, then, cutting the tight muscle at the stomach and food pipe junction, and lastly closing the internal lining with Hemoclips after exiting the tunnel.

Achalasia cardia is seen rarely in the pediatric population as less than 5% of all cases present below 15 years of age globally.
The procedure took 1½ hours and the child’s obstruction and blockage at the junction of the food pipe and stomach was immediately relieved (Figure 2).

This would not have been possible without the ardent team support of a well trained team of Endoscopic Assistants, Pediatrics Anesthetist and Pediatrics Surgeons.

After the surgery the child was able to consume a normal diet within 4 days and left the hospital smilingly.

POEM (Per Oral Endoscopic Myotomy) is an endoscopic procedure used to treat obstruction at the lower end of the food pipe due to failure of relaxation of lower esophageal sphincter (musculature opening) due to motility disorder called Achalasia Cardia. POEM is a relatively new advanced endoscopic procedure which can be performed in the endoscopic suite itself without any incision on chest or abdomen, with a minimal post- procedure stay.

According to Dr. Shivam Khare, “We believe that with increasing expertise and availability of multispecialty team this procedure can be safely done for long lasting relief from dysphagia (difficulty in swallowing) and regurgitation (vomiting) of food so that these hapless children can be properly treated and achieve the full potential of physical and mental growth especially in the formative year of early childhood and adolescence.”

Elaborating further, Prof. (Dr.) Anil Arora said, “With state-of-the-art advanced diagnostic procedures like high resolution esophageal manometry and high definition endoscopes, disorders like Achalasia Cardia can be easily diagnosed. We have already successfully performed this procedure in 427 cases till date in our hospital. But this procedure in a young child of 6 years weighing only 11 kg has been performed for the first time in India.”