Endoscopy 2018; 50(05): 550-551
DOI: 10.1055/s-0044-101024
E-Videos
© Georg Thieme Verlag KG Stuttgart · New York

Less invasive than minimally invasive: peroral endoscopic myotomy with a slim scope in the treatment of esophageal achalasia

Antonio Carlos Coelho Conrado
Advanced Endoscopy Unit, Restauração Hospital, Recife, Brazil
,
Joao Guilherme Guerra
Advanced Endoscopy Unit, AC Camargo Cancer Center, São Paulo, Brazil
,
Claudio Lyoiti Hashimoto
Division of Gastroenterology and Hepatology, University of São Paulo, São Paulo, Brazil
,
Marcelo Averbach
Division of Proctology at Sirio Libanes Hospital, São Paulo, Brazil
,
Miguel Arcanjo dos Santos
Surgical Department Federal University of Pernambuco, Recife, Brazil
,
Peter Vassilev Draganov
Advanced Endoscopy at Shands Hospital, Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, Florida, United States
› Author Affiliations
Further Information

Corresponding author

João Guilherme Guerra, MD
Endoscopy Unit – AC Camargo Cancer Center
R. Professor Antonio Prudente 211
Liberdade
São Paulo – SP, CEP 01509-010
Brazil   
Fax: +55-11-31479999   

Publication History

Publication Date:
16 February 2018 (eFirst)

 

Peroral endoscopic myotomy (POEM) is an established therapy [1] [2] [3]. We describe a new technique for POEM using a slim/pediatric endoscope, which aims to provide a less-invasive approach compared with traditional POEM.

A 16-year-old girl was diagnosed with achalasia based on symptoms (dysphagia, regurgitation, 6-kg weight loss over 4 months, Eckardt score of 7), barium swallow showing mildly dilated esophagus with retention of contrast ([Fig. 1]), and manometry demonstrating increased lower esophageal sphincter relaxation pressure of 13.1 mmHg.

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Fig. 1 Barium swallow demonstrating a mildly dilated esophagus with retention of contrast.

POEM was initiated using a standard gastroscope. A submucosal cushion was made with succinyl gelatin-methylene blue solution 8.0 cm proximally to the gastroesophageal junction. The endoscope was exchanged for a slim gastroscope (EG-530NW, 5.9 mm external outer diameter, 2.0 mm working channel; Fujifilm, Tokyo, Japan), fitted with a cap cut from the tip of a 5.5 mm endotracheal tube (Solidor; Well Lead Medical Co., Ltd, Guangzhou, China) ([Fig. 2]). A mucosal opening was made with the tip of an oval 13-mm polypectomy snare (Profile Snare; Boston Scientific, Marlborough, Massachusetts, USA), which was also used for the creation of the submucosal tunnel and myotomy ([Fig. 3 a], [Video 1]). A submucosal tunnel was dissected for 2.0 cm distally to the gastroesophageal junction. When further submucosal injection was needed, we utilized a 22-gauge needle (Injectra; MediGlobe, Achenmühle, Germany) by removing the needle and outer sheath, and using the inner sheath as an injection device. Myotomy was then performed from 2.0 cm below the mucosal opening to the end of the submucosal tunnel ([Fig. 3 b]). All steps were done with E-Cut, pure with 90 watts (SS601MCa; WEM, Sao Paulo, Brazil). The mucosal opening was closed using a single endoscopic clip (EzClip; Olympus, Tokyo, Japan) ([Fig. 3 c]). The following day the patient was asymptomatic and was discharged on soft food. At 2 months’ follow-up, her Eckardt score was 1 on a nonrestricted diet.

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Fig. 2 Slim gastroscope fitted with the transparent cap cut from the tip of an endotracheal tube.
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Fig. 3 Endoscopic images. a Aspect of the submucosal tunnel before myotomy. b Final aspect of the myotomy. c Mucosal opening closed with one endoscopic clip.

Video 1 Management of esophageal achalasia with peroral endoscopic myotomy using a slim gastroscope.

Georg Thieme Verlag. Please enable Java Script to watch the video.

POEM with a slim gastroscope is a feasible, safe, and effective procedure. The procedure is even less invasive than the standard POEM procedure.

Endoscopy_UCTN_Code_TTT_1AO_2AG

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Competing interests

None


Corresponding author

João Guilherme Guerra, MD
Endoscopy Unit – AC Camargo Cancer Center
R. Professor Antonio Prudente 211
Liberdade
São Paulo – SP, CEP 01509-010
Brazil   
Fax: +55-11-31479999   


Zoom Image
Fig. 1 Barium swallow demonstrating a mildly dilated esophagus with retention of contrast.
Zoom Image
Fig. 2 Slim gastroscope fitted with the transparent cap cut from the tip of an endotracheal tube.
Zoom Image
Fig. 3 Endoscopic images. a Aspect of the submucosal tunnel before myotomy. b Final aspect of the myotomy. c Mucosal opening closed with one endoscopic clip.