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Create a Free AccountProcedures - Endoscopic submucosal dissection (ESD)
Peroral endoscopic myotomy using an endoscopic dissector: another novel device in our toolbox
Peroral endoscopic myotomy (POEM) is a safe and effective technique for the management of achalasia and other nonachalasia motility disorders.1 However, it is technically challenging and time consuming with the use of multiple instruments often required for performing various steps associated with the procedure. While the procedural technique has remained homogeneous, various electrosurgical knives continue to evolve to prevent injuries to the surrounding structures and reduce the need for device changes.Peroral endoscopic myotomy (POEM) for achalasia developing after vertical banded gastroplasty with asymptomatic gastro-gastric fistula
Peroral endoscopic myotomy (POEM) has revolutionized the treatment landscape for achalasia. Randomized trials and meta-analyses have shown that its efficacy is comparable to the traditional reference-standard surgical approach represented by laparoscopic Heller’s myotomy (LHM), with an outstanding safety profile1,2; higher postoperative reflux rates seem to be associated with POEM over LHM, owing to the absence of an antireflux procedure. POEM has consequently been proposed as a first-line option over LHM, which may carry higher perioperative and postoperative risk, for patients with previous abdominal surgery or obesity.Endoscopic submucosal dissection and tunneling procedures using novel image-enhanced technique
Recent innovations in image-enhanced endoscopy allow early detection and management of GI lesions. In this study, we aim to analyze the utility of texture and color enhancement imaging (TXI) and red dichromatic imaging (RDI) during endoscopic submucosal dissection (ESD) and submucosal tunneling procedures.Endoscopic through-the-scope suturing
There is growing interest in closure of larger mucosal defects, given the increasing use of endoscopic resection for early GI neoplasia and the advent of submucosal endoscopy, including peroral endoscopic myotomy. Existing closure methods include through-the-scope clips, over-the-scope clips, and over-the-scope suturing. Although over-the-scope clips and over-the-scope suturing allow closure of large defects, both require endoscope removal for device application and may have difficulty in treating lesions in the proximal colon or the small intestine.Red dichromatic imaging in peroral endoscopic myotomy: a novel image-enhancing technique
A 40-year-old man presented with a 1-year history of difficulty in swallowing liquids and solids. His Eckhart’s score was 6 of 12. EGD showed dilated esophagus with liquid stasis and mild resistance noted across the gastroesophageal junction. Esophageal manometry showed elevated integrated relaxation pressure with panesophageal pressurization (achalasia cardia type II). Peroral endoscopic myotomy (POEM) was planned and was performed using the novel Evis X1 endoscopy (Olympus Corporation, Tokyo, Japan) system.Complementary role of EUS, EndoFLIP, and manometry for management of type III achalasia with peroral endoscopic myotomy in a patient with compensated cirrhosis and no varices
A 52-year-old woman with alcoholic cirrhosis was evaluated for dysphagia and found to have type III achalasia. Her cirrhosis was complicated by portal hypertension in the form of ascites and hepatic encephalopathy. Because of her decompensated cirrhosis, she was initially treated with balloon dilations, with minimal to no durable improvement in dysphagia. However, several months after cessation of alcohol use, her ascites and encephalopathy resolved, and she no longer required paracenteses and lactulose.Mucosa-preserving Zenker’s diverticulotomy
Zenker’s diverticulum (ZD) is a rare condition, with prevalence ranging between 0.01% to 0.11%.1 The mainstay of treatment is cricopharyngeal myotomy. Recently, flexible endoscopic cricopharyngeal myotomy (FECM) (Fig. 1) has become increasingly popular as a safe and effective alternative to open surgery and the rigid endoscopic approach. However, reported recurrence rates range from 0% to 32%,2 likely owing to a lack of procedure standardization and difficulty in performing adequate myotomy for fear of perforation, given the absence of mucosa preservation.Endoscopic techniques to detect gastroesophageal junction in peroral endoscopic myotomy
Peroral endoscopic myotomy (POEM) is now considered a first-line treatment modality for patients with achalasia.1 POEM is an attractive option for both physicians and patients because it is less invasive than laparoscopic Heller’s myotomy and more definitive than endoscopic balloon dilation. POEM is done as follows.2 Creation of a submucosal cushion 10 cm above the gastroesophageal junction (GEJ) is followed by making a mucosal incision to form the opening of the tunnel. Next, a tunnel is created with submucosal dissection till 2 to 3 cm below the GEJ.High-resolution manometry–guided endoscopic myotomy in a case with jackhammer esophagus
A 35-year-old man presented with a 3-year history of intermittent chest pain, dysphagia, and regurgitation (Eckardt score: 5). Gastroscopy and barium esophagogram revealed a normal-diameter esophagus with tertiary contractions in the mid and lower esophagus and no resistance at the gastroesophageal junction (GEJ) (Fig. 1). High-resolution manometry (HRM) showed a high distal contractile integral of 28,013 mm Hg/s/cm in >20% swallows, with a normal integrated relaxation pressure (12.8 mm Hg) and distal latency (7 seconds), suggestive of jackhammer esophagus (JHE) (Fig. 2).Evaluation of sling fibers and two penetrating vessels for guiding extent of the tunnel and myotomy during posterior peroral endoscopic myotomy in a Western cohort
Peroral endoscopic myotomy (POEM) was performed first in 2008 by Professor Inoue. Its use is now widespread as a first-line treatment for achalasia, with similar efficacy to Heller’s myotomy.1Peroral endoscopic fundoplication: a brand-new intervention for GERD
Minimally invasive treatments are preferred in any field of medical treatment. Relevant to that, we started peroral endoscopic myotomy (POEM) in 20081 as a minimally invasive endoscopic treatment for achalasia and related motility disorders. Use of POEM has spread all over the world. However, the potential risk of developing GERD after POEM has been reported in multiple studies.2 Seeking to prevent post-POEM GERD, we conducted a pilot study on the effectiveness of POEM + fundoplication (POEM+F)3 as a natural-orifice transluminal endoscopic surgery procedure using submucosal endoscopy with the mucosal flap safety valve technique reported by Sumiyama et al.Peroral endoscopic myotomy in a child with Triple A syndrome (Allgrove syndrome)
Triple A syndrome (AAA) or Allgrove syndrome is a rare, autosomal recessive disorder that usually manifests with 3 main cardinal symptoms: achalasia, alacrimation, and adrenal deficiency.1 A mutation on chromosome 12q13 for the ALADIN protein must be confirmed for the diagnosis.2Peroral endoscopic myectomy: a novel thought to reduce recurrence after previous failed myotomy
A 45-year-old man presented with a history of dysphagia and regurgitation for 8 years. He was diagnosed with type II achalasia cardia and underwent Heller’s myotomy without fundoplication 4 years earlier. The results of the present evaluation, including symptom analysis, EGD, timed barium esophagogram, and esophageal manometry, suggested a relapse. Treatment options were discussed, and peroral endoscopic myotomy (POEM) was performed. The posterior route (5 o’clock) was chosen for POEM to avoid possible submucosal fibrosis along the anterior route.Peroral endoscopic myotomy in a patient with failed Heller’s myotomy by use of a novel bipolar radiofrequency device
A 35-year-old woman presented with symptoms of dysphagia, regurgitation, and occasional chest pain for the previous 6 years. She was known to have type II achalasia and gave a history of laparoscopic Heller’s myotomy without fundoplication about 5 years earlier. Subsequently, she underwent pneumatic balloon dilatation (single session, 35 mm) for recurrent symptoms about a year after the Heller’s procedure. The present evaluation revealed a high integrated relaxation pressure and significant stasis on a timed barium swallow study.Greater-curvature peroral endoscopic myotomy with diverticuloseptotomy for the treatment of achalasia in a patient with a large epiphrenic diverticulum
Epiphrenic diverticula occur in the distal esophagus and are considered pulsion-type diverticula inasmuch as they occur secondary to a congenital weakness of the esophageal wall in conjunction with an esophageal motility disorder.1,2 They have been associated with esophageal dysmotility, predominantly achalasia.3,4 Symptomatic epiphrenic diverticula are usually managed surgically with laparoscopy involving diverticulectomy, myotomy, and anterior fundoplication.5 Alternative therapeutic options are limited for patients deemed poor surgical candidates.Functional luminal imaging probe technology to assess response after flexible endoscopic Zenker diverticulotomy
Zenker diverticulum (ZD) is rare, with an unknown overall prevalence, given that many patients with ZD are likely asymptomatic.1 ZDs are pseudodiverticula that manifest as mucosal and submucosal pulsion through the Killian triangle. Postulated mechanisms include increased intraesophageal pressure at an area of weakness in the proximal esophageal wall and hypertensive upper-esophageal sphincter (ie, decreased compliance). ZD is frequently diagnosed by esophagography. Symptoms include dysphagia, regurgitation, and, in severe cases, weight loss and malnutrition.“Posterior-like” anterior per-oral endoscopic myotomy
Per-oral endoscopic myotomy (POEM) can be performed by an anterior or a posterior approach to the esophageal wall, depending on the operator's preference. Recent data, however, show that posterior POEM is faster in accomplishing myotomy and in mucosal closure time, with less risk for inadvertent mucosal injury. These advantages are attributed to the axis of the dissection plane, which naturally parallels the endoscope working channel.Early experience with use of an endoscopic “hot” scissor-type knife for myotomy during per-oral endoscopic myotomy procedure
Current devices used for per-oral endoscopic myotomy (POEM) function predominantly to either cut tissue or coagulate vessels. When bleeding vessels are encountered within the submucosa or muscle, dedicated coagulation grasping devices are often necessary. An endoscopic “hot” scissor-type knife is available that combines coagulation and cutting functions. Scissor-type knives may therefore be helpful during the POEM procedure.
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