These fluoroscopic images show the development of distal esophageal distension (also referred to as a blown-out myotomy) in a patient with type II achalasia who underwent peroral endoscopic myotomy (POEM) with a 9 cm myotomy. At 6 months after POEM, barium esophagram (A) showed a normal caliber esophagus and non-occluding contractions. The distal esophagus was normal, and the esophagogastric junction (EGJ) demonstrated normal opening and dimensions (B). The 5-minute image showed complete emptying, and the patient's symptoms were in remission with an Eckardt score of 1. After 5 years, the patient presented with recurrent symptoms and an Eckardt score of 7. The barium esophagram (C) showed evidence of severe esophageal dilatation along the myotomy site and significant barium retention at 5 minutes. A blown-out myotomy is typically defined as a >50% increase in esophageal diameter at its widest point in the distal esophagus between the lower esophageal sphincter (LES) and 5 cm above the LES.
