Underwater peroral endoscopic myotomy was initially presented as an alternative approach
for the treatment of achalasia, with only a few case reports published since its initial
description [1]
[2]
[3]
[4]. The theoretical advantage of using saline infusion instead of carbon dioxide is
the diminished risk of gas-related events such as capnoperitoneum, tension pneumothorax,
or pneumomediastinum. However, in our experience, the major advantage of working under
saline is the stabilization of the endoscope in the setting of increased esophageal
motility. The purpose of this video ([Video 1]) is to illustrate the advantages of performing peroral endoscopic tunneling under
saline combined with partial myotomy in the setting of hypercontractile esophagus.
Demonstration of peroral endoscopic tunneling under saline combined with partial myotomy
for hypercontractile esophagus.Video 1
In this rare disorder, the increased motility of the esophagus ([Fig. 1]) makes the procedure challenging and raises the risk of inadvertent mucosal damage.
However, by performing the dissection under saline ([Fig. 2]), the mucosa floats away from the muscle layer and the spasms of the esophagus do
not interfere with the dissection plane. In addition, by performing partial myotomy
([Fig. 3]) during tunneling, the axis of the tunnel is straightened, and the intensity of
contractions is significantly diminished. When both techniques are applied, the procedure
becomes safer and faster. Once the tunnel is completed the saline is aspirated in
order to diminish the risk of postoperative pleural effusions, and standard myotomy
is performed ([Fig. 4], [Fig. 5]).
Fig. 1 Intense esophageal contractions in a case of hypercontractile esophagus.
Fig. 2 Tunneling under saline. The view is magnified, the mucosa floats away from the muscle
layer, and the contractions do not interfere with the dissection plane.
Fig. 3 Partial myotomy performed under saline.
Fig. 4 Full-thickness myotomy.
Fig. 5 High-resolution manometry before (a) and after (b) myotomy, showing loss of hypercontractility.
In conclusion, we believe that tunneling under saline combined with partial myotomy
is an innovative approach for faster and safer dissection in motility disorders with
intense esophageal contractions.
Endoscopy_UCTN_Code_TTT_1AO_2AP
E-Videos is an open access online section of the journal Endoscopy, reporting on interesting cases and new techniques in gastroenterological endoscopy.
All papers include a high-quality video and are published with a Creative Commons
CC-BY license. Endoscopy E-Videos qualify for HINARI discounts and waivers and eligibility is automatically checked during the submission
process. We grant 100% waivers to articles whose corresponding authors are based in
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by Research4Life (see: https://www.research4life.org/access/eligibility/).
This section has its own submission website at https://mc.manuscriptcentral.com/e-videos.
