Peroral Endoscopic Myotomy (POEM) for Achalasia

CHAPTER 1

So the procedure is called POEM, which stands for Peroral Endoscopic Myotomy, which is a way to perform esophageal myotomy purely in the lumen through the mouth without any incision to the abdomen like it used to be traditionally performed. In the past those surgeries were going from open to laparoscopic procedures with tiny little incisions, now it's done purely through the mouth. The procedure consists of using an endoscope of high-definition making an opening of the mucosa of the esophagus about 1.5 cm, and that's located 10 cm above the lower esophageal sphincter. Through that mucosotomy, we develop a submucosal tunnel. That tunnel is then advanced beyond the lower esophageal sphincter and about 2-3 cm into the stomach, into the cardic area. Then the scope is removed. The tunnel is inspected for the integrity of the mucosa. If there is any injury to the mucosa, we just place clips to avoid a through-and-through perforation and that probably occurs in about 2-3% of the cases. Then once all the tunnel has been inspected, and there was no problems, we then go to the myotomy portion, which we start 5 cm above the lower esophageal sphincter and advance 2-3 cm below the lower esophageal sphincter through the tunnel which was created. We perform a circular muscles myotomy, but a lot of the times, the longitudinal fibers also is cut, which is absolutely fine. In Japan and China, they do that all the time, At the end of the procedure, we place clips, interruptedly with about 7 clips to close the mucosotomy and finish the case.

CHAPTER 2

Okay, so let's go into the esophagus. Mm hmm. Wow. Yeah, exactly. I have another one like this they insist has achalasia that a barium tablet went through. Really? Yeah.

True trendelenburg, yes please. That's good there. Wow, okay. Okay, so that's right about whatever this mark is - I'd say we're right - that's it right there. Yeah I did. So that's 60, 55, 53.5, basically yeah. Okay, so if we come back 10, that's 50, 45, 43. Okay? All right.

Okay, Neal I'm just - I'll tell you what, let's - give me a little bit of blue stuff, right here, give me a little squirt. Okay, so that needs to be changed to that. Okay, that's good there. So let's just put the piece of tape on right now. Put it - hold on a second Elon, let me just see. So if we put it here… That's too far. Maybe let’s just get this back in view. So we should probably - We want to be able to get this, so probably you're going to feel that right about here. So probably right about here should be fine. Great, okay. Okay, let's have some blue again please. Okay, good. Okay, needle out. Put a little bit more in, Elon. Okay. Okay, needle out. Okay. Inject, slowly.

You're off, stop. Stop. You want to bring the needle back and just pierce that. Okay. Almost through-and-through and then you pull back. There you go, now pull back slowly. Yep. Inject. Yep. Pull back. Pull back, pull back, pull back. Okay. Keep pulling back. We're going to find the right position. Pull back, very good. Yep. Keep going. Pull back a little bit more. See, now it’s out - you can see that. Okay, stop. Needle in.

Okay, knife out. I'm going to suck on this right? Right, yellow. Yellow. So let's go - down a little bit in there. Go up just a hair because - right there. Okay. Keep moving me. Right, let's go down. More down. You have to do it. Yep. Nice. Good, yeah. Keep going. Push it in. Good, push back in a little bit. Pull back. And that's about it. The one thing you can control yourself is the section towards you. See this is - a lot of this is - happens from here. Like that. Okay. Because there's just so little degrees of freedom here. We need to get down towards 6 o'clock here. We need to get more room there, I think Right there. Pull back. I'm just going to get this area right in here. Yep. Should I cut the mucosa right there? Yeah, cut it right there. And also, I need you to cut over here. Let me pull back. Yep. Good, stop right there. There you can spray. Let's inject more blue because we lost somewhere. Yep. Yep. We can check right now. Yeah, see, I think we're almost all the way through. I'll inject. About 3 cc. That's good right there. Hook that. Yep. Actually, I think that's big enough, huh? Just hook that over that. Okay. Let me just find that little in there. Because there's the circular muscle, so we're good. Yep. So let me try to get this in. All right, I'll get this in for you. You need to go right here. This is what's got to go, right here. If we can get to it. Pull back a little bit.

CHAPTER 3

There you go. That's going to be a big step forward. All right Ozanan, I’ll twist this thing in if I can. Okay, so now it should be in. Deflect down, just deflect down. And go up. Okay, yep. I'm just going to make like 2 cm, I'll give it to you. Okay, yep. Okay, great. Push it in and down. And down, yep. Okay, so… All right, let’s switch here. Let's have the blue now, please. Yep. Okay, Elon. Check about 2 cc, please. Okay, good, stop there.

Keep going - advance - let’s get this thing right down here next. This is holding us. Yep. It's close to mucosa though. Yeah. Can you advance it? That's good there. Will that stay? Let me get you closer. That's definitely muscle there. Just pull it back and try to grab this Okay. Now we're just about through, I think. There we go. Back down the tunnel. The stuff right up here, or no? No, I don't think… Palisading vessels there, yeah. I don’t think that’s necessary to take these. Yeah, well, I think we need to take - we need to open this up, so… Yeah, up to the level of S1. That’s a good little inchworm move there. To the right? Yeah, to the right. I think we're going to have to zap that vessel before it bleeds in our face. Right there, right? Yeah. Spray. Yep. Yeah, but touch it. You can spray like a little bit lower. A little bit lower. There you go. So those are myotomized already. You want to be below this. Maybe we can inject again. Let’s see - Let’s go inside the mucosa and see how it - what we're doing. Okay, how far away are we? We're about 55? Yeah. Okay, let’s see - is there anything here easy we can take while we're sitting here? Well, my only concern is that you need to get this plane right here. Right, exactly, exactly. And then getting it off, so we need to inject blue over here. Yep. Let's inject right now. And then we can go back in look, yeah, I think so. Pull back just a touch here. Let's see here. I would. Looks like we should go right here. I was thinking almost right here. See this hole right there? Yeah, but let's see that hole again, let's see if that's muscle. See, there’s muscle on the other side of that. So get right down here is what you want, right? Yeah, then you have to apply gentle pressure. Yep okay, Elon, inject very slowly. Can I have the tiki knife, please. Okay, knife out. Pull back a little bit. Isn't this muscle right here? Here is muscle, right there. There's muscle, and then there's a very thin layer between the submucosal space, that’s where we want to go. Yeah. Okay, pull back. I don’t know about this, what do you think? There's some mucosa on the other side of that I know, but so close your needle right now. And just go and just probe it very gently. Just go a little bit more than that. See, those are fibers, right there. So the thing is, we should be raising a tunnel here. I’m just going to sort of scratch this downward - deflect downward with that, just because of rubbing it. I think we should just cut this right here. To do the myotomy? Sure. Yeah, right there. But then we are - the only downside is it's going to be like the other case, even if - and be able to ford a good tunnel because then... Okay. All right, so what do you want to do here? I want to just inject. All right, needle in. Now what you want to do is literally just - you see this submucosal tissue, right here? Yeah, right there. Inject on it, it's going to go… You happy with that, right about there? Just a little bit more. Okay starting to inject some more. Now, stop. Back the needle in. Needle back in. Needle in. Now we're going to apply pressure here where you made the hole. Okay, inject. Inject. You should get something. Okay, knife out. Yep. Yep, advance - push it in, Ozanan. Bring me across a little bit. Rotate me. Cross in between and back a little bit for that. Now we can put blue right there. Yep. I wonder if we can get any of this stuff right here while we’re at it. Can you rotate the scope and see? Come back, okay. That's yes up here, right? Mm hmm, because there must be muscles on top so that's fine right there. Looks too blown out. Okay. Can I get this little band right here or not? Or - no. Okay, all right let's go, okay. Pull this back a little bit. So what we’re going to do is we're going to pull this back, just stretch it very gently. There we go. You're in there. Okay, inject. Needle out. You have to take this right here - you have to take it. It's right on the muscle. That muscle. But that's okay, let's get back on it again. Now pull back slightly. Mm hmm. Pull back, pull back, pull back, let me rotate to the side. Can you deflect to the left a little bit? Back in a little bit. Deflect down. So now what we can do is from here - take that. Because that would be enough right there to do the myotomy. Yep. Okay. That's better. Mm hmm. Okay. Push in a little bit. Let’s just reassess our tunnel right now. All right, knife in. Let's take this out.

One thing's for sure the lower end of that myotomy is in the fat. Yeah. Mm hmm. Yeah. Mm hmm. And we did go past the palisading vessels, so there’s some hope there. Here, there we go. Okay. So you just kept twisting. I just kept twisting and I lost the curvature. Okay. And then plus, I’m going to take that directional flexion right now. Mm hmm. I'm going to pop it out. Because this is too sharp - our angle is too sharp. Okay. The other thing too is that if you go too far in retroflex, then you go to the... All right. All right, so we’re down there. We can see that, definitely. And now we pull back here. There we go right there. Mm hmm. And the distance of this tunnel is - through here, from the cap in centimeters, so… So… So what is that - keep coming back - what is that right now? So that’s 50. So it’s 4 cm each. So it’s 4 cm before squamocolumnar, so that ought to be enough. Yeah, mm hmm. All right. Because then you go back there and finish the myotomy. All right. Let me just put that there. Yep.

CHAPTER 4

Okay so start right here. Knife out. Make sure that we connect with the other myotomy. There’s a big vein right there. So let's just stay here, on this side.

Okay. Mm hmm. Can you deflect to the left a little bit? I think so too. There we go, that's the line we want to go to. Right here, right? Mm hmm, keep going. Like that? Mm hmm. Right there… Okay, I see that. Yep. That's longitudinal muscle. Okay. A little bit more - we got a few more fibers right here that'll have to go. That's the end of the... Yep. Well that's - let me pull back. Okay, ready? Mm hmm. Get this one up on top. Should we do the vessels behind it? Okay. I'm just pushing. Oh that’s empty space there, right? Yeah, that's… Perineum, yeah. Yeah. Okay, so we’re good there. Okay, all right, fine. Pull back.

Pull back - pull back - pull back - pull back - that’s myotomy - that’s myotomy - that’s myotomy - go a little bit more up here. Okay. Yeah, let’s make sure we have plenty. I think Elon's right - I think our measurements are off. I think you should cut from here to there. Knife out. You want me to push it in? Mm hmm. That’s all the way through. Yeah. Maybe just… Maybe just stop. Let's get the - Well that’s circular muscle right there, right? It kinda looks like it - let’s just cut this and… Yep. Knife out. Go back just a little bit. Okay, good. There you go, and that's it. Then just push it. Good, okay good. I think that’s pretty good. I think we're good. Okay.

CHAPTER 5

At your 2 o'clock. Got to rotate it. Good, okay. It’s not that bad of a the tunnel - I mean it’s… No, no. Advance this. I'll hold the scope for you. All right, it's up to you. Yeah… All right. Pull this back a little bit. You kind of want to have this open inside your cap first. Take your tip and deflect up with the tip of the scope. Yep. You know what? Let's see. So move the scope back down right now. And just hold there. It's okay for an… That's okay for a starting point I think, yep. All right. All right. Mm hmm. Clip's open. And then what I'm doing is I'm going to be deflecting up. Pushing it in, and then close. Close. Okay. So now whenever I just check. Test. It's okay.

CHAPTER 6

All finished. That was a peroral endoscopic myotomy. The case went pretty smoothly. A little trouble at the start getting the tunnel established, but once we got in, I think everything went pretty smoothly. I hope that you could appreciate on that video how things tightened up as we came across the lower esophageal sphincter and the palisading vessels, but once we got through that, everything went very easily. It's okay to go full-thickness through the esophagus as long as the tunnel itself is closed adequately, which you could see. We’ll get a gastrografin swallow tomorrow morning, make sure that there is no endoleak or problem with the tunnel, and if so, the patient will go home on a liquid diet for a week, and her achalasia should be fixed.