Peroral endoscopic myotomy has gained worldwide acceptance as one of the first nine treatment modalities along with pneumatic dilation and Heller myotomy For patients with achalasia During POEM procedures, the endoscopic needle knives are most commonly used for both submucosal tunneling and myotomy combined with hemostatic forceps for managing large vessels and active bleeding. Because of the imperative esophageal gastric junction relaxation in patients with achalasia, the limited space at the level of the EGJ increase the technical difficulty of tissue plane dissection and selective myotomy using the needle-type knife Besides, operators who are still going through the learning curve phrase could be less proficient in exchange for hemostatic forceps for bleeding control To minimize the technical difficulty and improve the safety of POEM, In this video, we described the protocol for using the seizure-type knife for the main steps of the POEM procedure, including mucosal incision submucosal tunneling, myotomy, and hemostasis. Identify the EGJ by the tight appearance.
Confirm the increased resistance when maneuvering the endoscope through the EGJ Note the location of the EGJ by measuring the distance from the incisors. Choose the ingestion point seven to nine centimeters proximal to the EGJ in the posterior wall of the esophagus. Inject the saline with the methylene blue into the submucosal space with the endoscopic ingestion needle.
Make a 1.5 to two centimeter longitudinal mucosal incision with the scissor-type knife. Rotate the blade of the scissor-type knife parallel to the master layer. Then, and this side the submucosal tissue to create a submucosal tunnel toward a two to three centimeter below the EGJ.
Keep the dissection plane close to the muscle layer Inject the saline with the methylene blue into submucosal tissue. To expand the working space with tunnel progression Confirm the adequate submucosa tunnel lens by the blue discoloration of the gastric submucosa on the rich place view. Use the scissor-type knife for the interoperative vessel ceilings and bleeding controls without trending the hemostatic forceps.
Begin the myotomy at approximately two centimeter distal to the mucosal entry, selective grace and descent. The internal circular muscle bundle with the scissor-type knife. Standard myotomy two to three centimeter onto the gastric cardio Complete the completion of myotomy confirmed the most passenger through the EGJ by reinserting.
The endoscopy into the Close the mucosal entry with the indoor clip Compared with the needle-type knife. The scissor-type knife enables coagulation and the dissection after grasping the target tissue. Meanwhile, the scissor-type knife is scripted with the enhanced hemostatic capability.
Similar to hemostatic forceps an insulated coating external of the two blades. Three patients with achalasia received POEM using the scissor-type knife. In our institution sigmoid esophagus was present in one patient.
One patient had previously undergone pneumatic dilation. Technical success were achieved in all patients with no preoperative adverse evidence occurring. All bleeding controls and vessel ceilings in this very POEM procedures were managed by the scissor-knife without the use of hemostatic forceps.
The procedure time was 60 45 and 40 minutes, respectively. At three months follow-up, all patients achieved clinical success with postoperative recorded scores ranging from zero to one. The postoperative high resolution manometry and burial esophagal data showed it significant reductions in lower esophageal sphincter pressure four seconds integrated relaxation, pressure, and esophageal diameter.
One patient had an endoscopic finding of low grade esophagitis without reflex symptoms. The use of the scissor-type knife could minimize the technical difficulty and improve the safety of POEM procedures, which may be suitable for trainees during the learning curve phrase. Future large randomized controlled trials admitted confirm the safety, efficacy, and learning curve of using the scissor-knife for POEM compared with conventional knives.
