Peroral Endoscopic Myotomy (POEM) for Achalasia
- Creation of Mucosal Incision
- Irrigate Gastric and Esophageal Lumen
- Identify Squamocolumnar Junction
- Check Orientation of Scope
- Create Submucosal Cushion
- Create 1.5 cm Vertical Mucosal Incision
- Submucosal Tunneling
- Use Indigo Carmine/Epinephrine Sol'n to Lift Mucosa Off Circular Muscle Fibers
- Advance Distally Taking Care not to Injure Mucosa
- Assess Location of Tunnel
- Start at Convenient Point and Work Distally
- Perform Selective Myotomy of Circular Muscle Fibers
- Re-assess Integrity of Mucosa
- Closure of Mucosal Incision
- Use Clips to Close Incision
TranscriptionsPlease note that, unless otherwise stated, these transcriptions have been auto generated and therefore we can not guarentee their complete accuracy
So the procedure is called POEM, which stands for Per-Oral Endoscopic Myotomy, which is a way to perform esophageal myotomy 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 and 1/2 CM index located 10 centimeters above the lowers of produced sphincter through that new 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 was inspected for the integrity of the mucosa. If there is any injury to the mucosa, we just place clips to provide through and through perforation and that probably occurs in about 2- 3 percent 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 lowers of produced sphincter and advance 2-3 cm below the lowers of produced sphincter through the tunnel which was created. We perform a circular muscles myotomy, but a lot of the time, the longitudinal fibers are also cut which is 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.
Assembly line. So can I have another large syringes at 16 with the - with the regular tip? Let's go into the esophagus. I have another one like this that they insist has achalasia that a barium tablet went through. Yeah. Two turn over, yes please. That's good there. Wow, okay. That's right about whatever this mark is - I think - that's it right there. So that's 60 55 53 and a half basically yeah. Okay, so if we come back down, 50 45 43. Let's have a little - let's have the needle please.
And then let's go and get a piece of tape ready. Okay, Neal, I'm just - I’ll tell you what - 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. They're 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 here. So we should probably - We want to be able to get this so you’re probably going to feel 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. K. Jack. Voule. Stop. It's on the right position. Keep going. So now it’s out - you can see that. Okay, stop. Needle in. You have to be right. Okay knife out. I'm going to suck on this. Right. Alright, yowel. Yowel. K. Keep moving me. More down. You have to do it. See this - this - a lot of this 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 going to get this area right in here. Cut to me to right there. Good, stop right there. Let’s inject more blue because we lost somewhere. Yeah. I think we're almost all the way through. Check. That’s good, right here. That. Hmmm. Check is big enough. Just hook that over that. 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. There you go.
Okay, take a big step forward. Awesome. I’ll twist this thing in if I can. Piece of tubing - deflect down, just deflect down - and go out. Okay, it's going to be 2 centimeters to you. Okay great. Down. Alright, let’s switch here. Let’s have the blue now here 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. It’s close to mancosa though. Okay, that’s good there. That’s fine. That’s definitely muscle there. We’re just about through I think. There we go. Dissect down the tunnel. Step right up here, and I’ll - So pulsating vessels, yeah. I don’t think that’s necessary. Here, well, I think we need to open this up. So - yeah. That’s a good little inchworm move there. To the right. Right there. Spray. Yeah, suction. Let’s see. Let’s go inside the hallway. Okay, how far away are we? About 55? Okay, let’s see - is there anything easy we can take while we’re sitting here? Right, exactly, exactly. Should inject blue over here. We can 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 right here. See this hole right there? See, there’s muscle on the other side of that. Okay, right down here is what you what. Right? Okay, Eli, inject very slowly. Have the tiki knife please. Okay, knife out. Isn’t this muscle right here? The mucosal space, that’s where we want to go. I don’t know about this, what do you think? On the other side of that - I know, but just go just a little bit. Just go a little bit more than that. See, those are fibers, right there. We should be raising a tunnel here. I’m going to scratch downward - deflect downward with that. That guy is rubbing it. I think we should just cut this right here. For the myotomy? Yeah. Sure. But then - what do you want to do here? I want to - needle in. What I want to do is literally just inject - right about there? Just a little bit more. Inject more. Now stop. Needle in. Apply pressure here and hold. Okay, inject.
Okay, knife out. Advance - push it in Oz. Bring me across a little bit. Okay. Back a little bit there. Now we’ll go right there. I can get this stuff while we’re at it. Can you rotate the scope? Yes - up here, right? I get this little band right here or not? No. Okay. So let’s go. Okay. So we’re going to stretch right here. There we go. Okay. Inject. Needle out. You have to take this right here - you have to take it. So now what we do is come here - take that. Yeah. That’s better. Okay. Push in a little bit. Let’s just reassess our tunnel right now. Okay, knife in.
One thing for sure is the lower in that myotomy is in the fat. And we did go past the pulsating vessels, so there’s some hope there. So you just kept twisting - just kept twisting. I’m going to take the reverse flexion right now. This is too sharp - it’s too sharp. The other thing two is that you went too far in reverse flexion. Then you go to the anterior - so alright - so we’re down there. Ah, definitely. And now we pull back here. I still don’t know why this should be here - so what - so what is that - keep coming - what is right now? So, that’s 50. So, it’s four centimeters each - so it’s four centimeters before squamocolumnar. It should be enough. Now, wait, push in just a little bit. I’m going to deflect up. Yeah.
Okay so start right here. Knife out. Make sure we connect with the other myotomy. There’s a big vein right there. I think so too. So, right here, right? Like that. The longitudinal muscle - okay. A little bit more - we got a few more fibers right here that have to go. It looks kinda - okay, ready. 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 - 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 - I think our measurements are off. Knife out. That’s all the way through. Yeah. It’s a - maybe just stop. 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.
Good. Okay. It’s not that bad in the tunnel - I mean it’s. I’ll hold this. Yeah. Kinda want to have this over. Take your chip and deflect up from the tip of the skull. Yeah. That’s okay for a starting point I think, yeah.
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 pulsating 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.
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