Introduction: For patients with end-stage Achalasia with sigmoid esophagus who have failed previous surgical repairs are currently offered esophagectomy with conduit reconstruction. This operation carries significant morbidity and mortality and may be ill-suited for patients whom are poor surgical candidates. In this video we present an endoscopic procedure to plicate and narrow the esophagus as an alternative to an esophagectomy.

Methods: We present an 84 year old male with long-standing achalasia who had undergone multiple prior treatments including endoscopic balloon dilation and laparoscopic Heller myotomy with Dor fundoplication but still experienced recurrent symptoms of dysphagia. He experienced multiple hospital admissions for dehydration and anemia secondary to esophageal ulcers from his megaesophagus. We performed an endoscopic plication of his esophagus with an endoscopic suturing device. We demonstrate our technique of taking full thickness running suture throws transversely along the partial diameter of the esophagus. The suture is cinched, anchored and released and another row of sutures is taken moving distal to proximal in order to narrow and straighten the dilated esophagus along its axis.

Results: Following the procedure the patient was progressed from a liquid to a soft diet with marked improvement in his achalasia symptoms and near resolution of his dysphagia. Post-procedure esophagram at follow-up demonstrates a smaller, narrower and straighter esophagus with improved esophageal emptying time.

Conclusion: Per oral plication of esophagus offers patients with end-stage achalasia who are poor surgical candidates for esophagectomy a low risk, well tolerated endoscopic alternative.