Technically simplified peroral endoscopic myotomy: blunt dissection making submucosal tunneling fast and safe

As a primary treatment for patients with achalasia [1], peroral endoscopic myotomy (POEM) is a technically demanding procedure [2]. To perform a high-quality POEM and to prevent complications such as leakages, infections, major bleeding, and gas-related events, the establishment of a submucosal tunnel and the integrity of the mucosal flap are crucial [3] [4]. We present a blunt dissection technique to achieve rapid and safe submucosal tunneling in the aim to build a technically simplified POEM, which we call blunt POEM ([Video 1]).

Video 1 The establishment of a novel peroral endoscopic myotomy (POEM) using a blunt dissection-based submucosal tunneling technique.

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A 58-year-old woman suffered from solid food dysphagia and regurgitation. The endoscopy presented two surgical scars ([Fig. 1 a, b]) and a contraction ring at the lower esophagus ([Fig. 1 c]). The patient was diagnosed with type II achalasia under barium esophagography ([Fig. 1 d]) and high resolution esophageal manometry. We decided to perform POEM on the patient. Briefly, a mucosal incision was made on the posterior esophageal wall ([Fig. 2 a]). Once the endoscope was maneuvered into the submucosal space, the transparent cap was applied to bluntly dissect the fibers and thus establish a submucosal tunnel ([Fig. 2 b]). The blunt dissection was so efficient that it took only 2 minutes to establish a 10-cm tunnel ([Fig. 2 c]). After the submucosal tunnel was extended 2 cm into the proximal stomach, the selective inner circular myotomy and full-thickness myotomy were conducted ([Fig. 2 d]). Finally, the mucosal entry was closed using endoclips ([Fig. 2 e]). After the procedure, the lower esophageal sphincter (LES) was open and the endoscope smoothly passed the cardia ([Fig. 2 f]).

Fig. 1 The diagnosis of achalasia after endoscopic submucosal dissection of early esophageal cancer. a One surgical scar on the right esophageal wall 24 cm away from the incisors. b Another esophageal scar 34 cm away from the incisors. c Contractile closed cavity was seen at the lower esophagus under endoscopy. d A beaklike narrow ring presented at the lower esophagus on barium esophagography.

Fig. 2 The establishment of a novel peroral endoscopic myotomy (POEM) using blunt dissection-based submucosal tunneling technique. a A 1.5-cm to 2-cm longitudinal mucosal opening was made after a submucosal cushion was created with the methylene blue saline solution. b The endoscope with a transparent cap fitted on its tip was drilled into the submucosal layer to create the working tunnel by bluntly dissecting fibers with the transparent cap. c A wide submucosal tunnel was established rapidly and safely as care was taken with the orientation of the endoscope. d Myotomy was performed from 2 cm below the mucosal opening to the end of the submucosal tunnel. e The mucosal opening was closed using endoscopic clips. f After the procedure, the cardia was relaxed and the endoscope was passed through it smoothly.

The simplest strategy to establish a tunnel is to dissect the submucosal fibers without a knife, and the most effective way to prevent complications is to preserve the intact mucosal flap [5]. In the current method of blunt POEM, we developed blunt dissection to simultaneously create a safe tunnel and preserve the mucosal flap. Compared with traditional POEM, blunt POEM is more easily maneuverable and less time-consuming for the treatment of achalasia.

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• References

• 1 Ponds FA, Fockens P, Lei A. et al. Effect of peroral endoscopic myotomy vs. pneumatic dilation on symptom severity and treatment outcomes among treatment-naive patients with achalasia: a randomized clinical trial. JAMA 2019; 322: 134-144
• 2 Khashab MA, Sethi A, Rosch T. et al. How to perform a high-quality peroral endoscopic myotomy?. Gastroenterology 2019; 157: 1184-1189
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• 4 Nabi Z, Ramchandani M, Chavan R. et al. Peroral endoscopic myotomy in treatment-naive achalasia patients versus prior treatment failure cases. Endoscopy 2018; 50: 358-370
• 5 Yamasaki M, Kume K, Yoshikawa I. et al. A novel method of endoscopic submucosal dissection with blunt abrasion by submucosal injection of sodium carboxymethylcellulose: an animal preliminary study. Gastrointest Endosc 2006; 64: 958-965