Endoscopy 2020; 52(01): E37-E38
DOI: 10.1055/a-0986-3112
E-Videos
© Georg Thieme Verlag KG Stuttgart · New York

A simple modification in technique preserves oblique muscle fibers during peroral endoscopic myotomy

Zaheer Nabi
1  Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
,
Mohan Ramchandani
1  Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
,
Rama Kotla
2  Department of Anesthesia, Asian Institute of Gastroenterology, Hyderabad, India
,
Radhika Chavan
1  Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
,
Santosh Darisetty
2  Department of Anesthesia, Asian Institute of Gastroenterology, Hyderabad, India
,
D. Nageshwar Reddy
1  Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India
› Author Affiliations
Further Information

Corresponding author

Zaheer Nabi, MD
6-3-661, Asian Institute of Gastroenterology
Hyderabad-500082
India   

Publication History

Publication Date:
21 August 2019 (online)

 

A 15-year old boy was diagnosed with type II achalasia cardia at our hospital and peroral endoscopic myotomy (POEM) was performed by the posterior route (5 o’clock). The standard steps of the POEM procedure included: mucosal incision, submucosal tunneling, myotomy, and closure of the incision with endoclips [1]. We incorporated an important modification in our myotomy technique in order to preserve the oblique muscle fibers close to the gastroesophageal junction.

In this technique, we identified two penetrating vessels at the gastric end of submucosal tunnel ([Fig. 1 a, b]). These vessels have been described as a marker of the junction between the circular and oblique muscle fibers [2]. The second penetrating vessel was not coagulated and served as a guide for later identification of the oblique muscle fibers. Myotomy was performed in the usual fashion until the gastroesophageal junction was reached. Subsequently, the direction of the myotomy was re-adjusted in such a fashion that it was possible to selectively avoid severing the oblique muscle fibers ([Fig. 1 c]). A lax gastroesophageal junction could be appreciated after the POEM procedure ([Fig. 2]). Finally, the mucosal incision was closed with the standard technique using multiple endoclips ([Video 1]).

Zoom Image
Fig. 1 Endoscopic views during peroral endoscopic myotomy showing: a the first penetrating vessel, which was revealed during submucosal tunneling towards the gastric side; b the second penetrating vessel marking the junction between the oblique (left) and circular muscle fibers (right), with the knife pointing towards the oblique muscle fibers; c endoscopic myotomy being performed towards the right of the second penetrating vessel, thereby preserving the oblique muscle fibers.
Zoom Image
Fig. 2 Endoscopic appearance after completion of the myotomy showing the lax gastroesophageal junction.

Video 1 Video demonstrating the technique to preserve the oblique muscle fibers during peroral endoscopic myotomy.


Quality:

POEM has emerged as a safe and efficacious treatment modality for achalasia cardia, with encouraging results in the pediatric population as well [3]; however, gastroesophageal reflux disease (GERD) is a major concern after POEM [4]. The oblique fibers form an important component of the anti-reflux barrier and are usually severed during posterior POEM. In this video, we demonstrate a novel technique for POEM in which the oblique fibers are preserved to prevent GERD.

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Competing interests

None


Corresponding author

Zaheer Nabi, MD
6-3-661, Asian Institute of Gastroenterology
Hyderabad-500082
India   


Zoom Image
Fig. 1 Endoscopic views during peroral endoscopic myotomy showing: a the first penetrating vessel, which was revealed during submucosal tunneling towards the gastric side; b the second penetrating vessel marking the junction between the oblique (left) and circular muscle fibers (right), with the knife pointing towards the oblique muscle fibers; c endoscopic myotomy being performed towards the right of the second penetrating vessel, thereby preserving the oblique muscle fibers.
Zoom Image
Fig. 2 Endoscopic appearance after completion of the myotomy showing the lax gastroesophageal junction.