PREPRINT
jkl keys enabled
417 views

Peroral Endoscopic Myotomy (POEM) for Achalasia

Transcriptions

CHAPTER 1

So the procedure is called POEM, which stands for Per-Oral 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 for using an endoscope of high-definition making a opening of the mucosa of the esophagus about 1 1/2 CM index located 10 centimeters above the lower esophageal sphincter through that mucosotomy we develop a submucosa tunnel. That tunnel is then advanced beyond the lower esophageal sphincter in about 2- 3 cm into the stomach into the cardiac 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, 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, and at the end of the procedure, we place clips, interrupted, leave about 7 clips to close the mucosotomy and finish the case.

CHAPTER 2

Assembly line. So can I have another large syringe at 16 with the - with the regular tip? Let's go into the esophagus. Yeah exactly, I have another one like this that they insist has achalasia that a barium tablet went through. Really? Yeah. Two trendelenburg, yes please. That's good there. Wow, okay. That's right about whatever this mark is - let’s say we’re right - that's it right there. Yeah I did. So that's 60 55 53 and a half basically yeah. Okay, so if we come back down, 50 45 43. Okay? Alright. Let's have a little - let's have the needle please.

And then let's get a piece of tape ready. 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 Eli - 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 would be fine.

Great okay. Okay, let's have some blue again please. Okay, good. K, needle out. Put a little bit more - a little bit more in Eli. Okay. Okay, needle out. Okay inject slowly. You’re off - stop. Just pierce that. Okay yep. Pull back, there you go now pull back. Slowly inject yep. Pull back. Pull back you're going to find the right position. Keep going. Pull back a little bit more. So now it’s out - you can see that. Okay, stop. Needle in.

Okay knife out. I'm going to suck on this right? Right yaw. Down a little bit here. Okay. Keep moving me. More down. You have to do it. And that’s about it. See this is - a lot of this is - happens from here. Like that. This - cuz there's just so little degrees of freedom here. We need to get down towards 6 o’clock here. I’m just going to get this area right in here. Cut the mucosa right there. Good, stop right there. Let’s inject more blue because we lost somewhere. We can check right now. Yeah. I think we're almost all the way through. Eyeline check. That’s good right there. Hook that. Checking this big enough. Just hook that over that. Okay this is fine now. Cuz there’s a circular muscle, so we’re good. Alright, I’ll get this in for ya. You need to go right here. This is what’s got to go, right here. If we can get to it. Go back a little bit. There you go.

CHAPTER 3

Okay, big step forward. Awesome. I’ll twist this thing in if I can. Deflect down, just deflect down - and go up. Okay yep, it's going to be 2 cm to you. Okay. Okay great. Push it in. Down, yep okay. So - alright, let’s switch here. Let’s have the blue now please. Okay, Eli. Check about 2 cc’s please. Ok good, stop there.

Keep going - advance - let’s get this thing right down here next. This is holding us. It’s close to mucosa though. Okay, that’s good there. That’s fine. Definitely muscle there. Turn. Now we’re just about through I think. There we go. Dissect down the tunnel. Step right up here, and I’ll - palisading vessels here yeah. I don’t think that’s necessary. Yeah, well, I think we need to take – we need to open this up so. That’s a good little inchworm move there. Yeah to the right. Right there, right? Spray. You can spray like a little bit lower. You want to be below this. Yeah, suction. Let’s see. Let’s go inside and get closer to see how we're doing. Okay, how far away are we? About 55? Okay, let’s see - is there anything easy we can take while we’re sitting here? My only concern is that you need to get this plane right here - Right exactly exactly. So we need to inject blue here - yeah. Let’s inject right now - and then we can go back in look, yeah, I think so.

Pull back just a touch here. Looks like we should go right here. I was thinking almost right here. See this hole right there? See, there’s muscle on the other side of that. Right down here is what you want, right? Yeah then have to apply gentle pressure. Yep okay, Eli, inject very slowly. Have the tiki knife please. Okay, knife out. Isn’t this muscle right here? There's a very thin layer between submucosal space, that’s where we want to go. 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. We should be raising a tunnel here. I’m just going to sort of scratch this downward - deflect downward with that. Like I was rubbing it. I think we should just cut this right here. To do the myotomy? Yeah right there. Sure. But then we are - the only downside is going to be we have a case even if we won't be able to shorten the tunnel because then – Okay. Alright so what do you want to do here? I want to inject - needle in. Now what you want to do is literally just - see this submucosal tissue right here? Yeah right there. Inject on it, it's going to go – you happy with that? Just a little bit more. Okay starting to inject the line. Now stop. Inject the needle in. Needle back in. Needle in. Now we're going to apply pressure here where you made the hole. Okay, inject. You should get something.

Okay, knife out. Yeah. Advance - push it in Azim. Bring me across a little bit. Rotate me. Now we can put blue right there. Yeah. I wonder if we can get any of this stuff right here while we’re at it. Can you rotate the scope and see? Yes, yes up here, right? I get this little band right here or not? Uh no. Okay. Pull this back a little bit. So we’re going to stretch this very gently. There we go. Okay. Inject. Needle out. Have to take this right here - you have to take it. Can you deflect to the left a little bit? So now what we can do is from here - take that. Because that will be enough to do the myotomy. Yeah. That’s better. Okay. Push in a little bit. Let’s just reassess our tunnel right now. Alright, knife in.

One thing’s for sure the lower end of that myotomy is in the fat. And we did go past the palisading vessels, so there’s some hope there. So you just kept twisting. I just kept twisting and - Okay. Plus I’m going to take the reverse flexion right now. Because this is too sharp – the ring is too sharp. The other thing too is if you go too far in reverse flexion. Then you go to the anterior - alright - so we’re down there. We can see that definitely. And now we pull back here. And the distance of this tunnel is - so what - so what is that - keep coming back - what is that right now? So, that’s 50. So, it’s 4cm each. So it’s 4cm before squamocolumnar. So that oughta be enough. Push in just a little bit. I’m going to deflect up. Yeah.

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. I think so too. So, right here, right? Like that? Okay, see that. Yep. It’s longitudinal muscle. Okay. A little bit more - we got a few more fibers right here that have to go. Okay, ready. Get this one up on top. Oh that’s empty space there, right? That’s perineum. Yeah. So we’re good there. Okay, alright 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. Let’s make sure we have plenty. I think Eli’s right - I think our measurements are off. Knife out. That’s all the way through. Yeah. Maybe just stop. Let’s get the - Well that’s circular muscle right there, right? It kinda looks like it - let’s just cut - yeah. Knife out. Okay good. I think that’s pretty good. Let’s - okay.

CHAPTER 5

Good. Okay. It’s not that bad in the tunnel - I mean it’s. I’ll hold this. Kinda want to have this open. Take your chip and deflect up from the tip of the skull. So move the scope back down right now. That’s okay for a starting point I think, yeah. So now we're going to just check. Test. It's okay.

CHAPTER 6

All finished. That was a peroral endoscopic myotomy. Case went pretty smoothly. 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.