Commentary

Bleeding during peroral endoscopic myotomy (POEM) can make the procedure technically challenging by hampering endoscopic visualization and obscuring dissection planes because of staining of tissues with blood. This can add to the procedure time and also cause serious adverse events. Hence prophylactic coagulation of vessels can be very helpful. In this video, Capogreco and colleagues describe a new method of “underwater” coagulation of vessels using the HybridKnife (Erbe, Tubingen, Germany) by filling the tunnel with saline [1]. The video nicely demonstrates vessel coagulation underwater, but the suggested mechanism and benefit of this approach causing soft sealing of the vessel under saline (without transecting it) needs to be proved. Also, details about the electrosurgical settings used by the authors for this technique would be helpful, especially if different from standard practice. Of note, we have been prophylactically treating blood vessels routinely during POEM with “low coagulation” (forced coagulation, effect 0.5, Vio 3 electrosurgical generator; Erbe, Tubingen, Germany) with the HybridKnife after skeletonizing the vessel, without switching to a coagulation forceps. Hence, further studies evaluating the proposed new technique and its clinical outcomes compared to existing hemostatic strategies will be essential.

Publication History

Article published online:
27 June 2024

• References

• 1 Capogreco A, de Sire R, Massimi D. et al. Underwater coagulation using hybrid knife in peroral endoscopic myotomy for achalasia. Endoscopy 2024; 56: E197-E198 DOI: 10.1055/a-2258-8371. (PMID: 38388954)