Use of the Scissor-Type Knife During the Peroral Endoscopy Myotomy Procedure for the Treatment of Achalasia
March 3rd, 2023
To minimize the technical difficulty and improve the safety of peroral endoscopic myotomy (POEM), we describe a protocol for using a scissor-type knife for the main steps of POEM, including mucosal incision, submucosal tunneling, myotomy, and hemostasis.
Peroral endoscopic myotomy has gained worldwide acceptance as one of the first nine treatment modalities along with pneumatic dilation and Heller myotomy For patients with achalasia During POEM procedures, the endoscopic needle knives are most commonly used for both submucosal tunneling and myotomy combined with hemostatic forceps for managing large vessels and active bleeding. Because of the imperative esophageal gastric junction relaxation in patients with achalasia, the limited space at the level of the EGJ increase the technical difficulty of tissue plane dissection and selective myotomy using the needle-type knife Besides, operators who are still going through the learning curve phrase could be less proficient in exchange for hemostatic forceps for bleeding control To minimize the technical difficulty and improve the safety of POEM, In this video, we described the protocol for using the seizure-type knife for the main steps of the POEM procedure, including mucosal incision submucosal tunneling, myotomy, and hemostasis. Identify the EGJ by the tight appearance.
Confirm the increased resistance when maneuvering the endoscope through the EGJ Note the location of the EGJ by measuring the distance from the incisors. Choose the ingestion point seven to nine centimeters proximal to the EGJ in the posterior wall of the esophagus. Inject the saline with the methylene blue into the submucosal space with the endoscopic ingestion needle.
Make a 1.5 to two centimeter longitudinal mucosal incision with the scissor-type knife. Rotate the blade of the scissor-type knife parallel to the master layer. Then, and this side the submucosal tissue to create a submucosal tunnel toward a two to three centimeter below the EGJ.
Keep the dissection plane close to the muscle layer Inject the saline with the methylene blue into submucosal tissue. To expand the working space with tunnel progression Confirm the adequate submucosa tunnel lens by the blue discoloration of the gastric submucosa on the rich place view. Use the scissor-type knife for the interoperative vessel ceilings and bleeding controls without trending the hemostatic forceps.
Begin the myotomy at approximately two centimeter distal to the mucosal entry, selective grace and descent. The internal circular muscle bundle with the scissor-type knife. Standard myotomy two to three centimeter onto the gastric cardio Complete the completion of myotomy confirmed the most passenger through the EGJ by reinserting.
The endoscopy into the Close the mucosal entry with the indoor clip Compared with the needle-type knife. The scissor-type knife enables coagulation and the dissection after grasping the target tissue. Meanwhile, the scissor-type knife is scripted with the enhanced hemostatic capability.
Similar to hemostatic forceps an insulated coating external of the two blades. Three patients with achalasia received POEM using the scissor-type knife. In our institution sigmoid esophagus was present in one patient.
One patient had previously undergone pneumatic dilation. Technical success were achieved in all patients with no preoperative adverse evidence occurring. All bleeding controls and vessel ceilings in this very POEM procedures were managed by the scissor-knife without the use of hemostatic forceps.
The procedure time was 60 45 and 40 minutes, respectively. At three months follow-up, all patients achieved clinical success with postoperative recorded scores ranging from zero to one. The postoperative high resolution manometry and burial esophagal data showed it significant reductions in lower esophageal sphincter pressure four seconds integrated relaxation, pressure, and esophageal diameter.
One patient had an endoscopic finding of low grade esophagitis without reflex symptoms. The use of the scissor-type knife could minimize the technical difficulty and improve the safety of POEM procedures, which may be suitable for trainees during the learning curve phrase. Future large randomized controlled trials admitted confirm the safety, efficacy, and learning curve of using the scissor-knife for POEM compared with conventional knives.
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Overview
This article presents a protocol for performing peroral endoscopic myotomy (POEM) using a scissor-type knife. The focus is on enhancing safety and reducing technical difficulties during the procedure.
Key Study Components
Area of Science
- Endoscopic surgery
- Gastroenterology
- Esophageal disorders
Background
- POEM is a minimally invasive treatment for achalasia.
- Traditional techniques often involve needle-type knives, which can be challenging.
- Operators may face difficulties with hemostatic control during the procedure.
- Improving the method can enhance patient safety and outcomes.
Purpose of Study
- To describe a safer and easier protocol for POEM.
- To utilize a scissor-type knife for key steps in the procedure.
- To facilitate better hemostasis and reduce complications.
Methods Used
- Identification of the esophagogastric junction (EGJ).
- Measurement of distance from incisors to locate the incision point.
- Injection of saline with methylene blue into the submucosal space.
- Execution of mucosal incision, submucosal tunneling, myotomy, and hemostasis.
Main Results
- The scissor-type knife effectively facilitated the POEM procedure.
- Improved safety and reduced technical challenges were observed.
- Enhanced hemostatic control was achieved during the procedure.
- Operators reported increased confidence using the new protocol.
Conclusions
- The scissor-type knife is a viable alternative for POEM.
- This method can improve patient outcomes and procedural safety.
- Further studies may validate these findings across broader populations.
Frequently Asked Questions
Executive Industry Relevance
This protocol addresses technical challenges in peroral endoscopic myotomy (POEM) for achalasia, a condition requiring precise esophageal muscle dissection. By integrating dissection and hemostasis in a single scissor-type device, the method reduces procedural complexity and device exchange, supporting safer adoption in training environments. The approach enhances predictability in tissue plane control, which is critical for minimizing intraoperative risks and improving early-stage operator confidence.
Strategic Applications in Biopharma R&D
Early Discovery & Target Validation
- Scientific Value: Enables precise interrogation of muscular layer function through controlled, selective myotomy of the internal circular muscle.
- Operational Value: Reduces reliance on multiple instruments, streamlining workflow and decreasing procedural variability during skill acquisition.
Screening & Assay Development
- Scientific Value: Provides a reproducible tissue preparation model for evaluating therapeutic effects on esophageal motility and sphincter function.
- Operational Value: Supports standardized submucosal tunneling and mucosal closure, facilitating consistent assay conditions across operators.
Translational & Preclinical Research
- Scientific Value: Offers a disease-relevant system to study neuromuscular mechanisms of achalasia and test pharmacologic agents targeting smooth muscle contraction.
- Operational Value: Enables longitudinal assessment of functional outcomes through postoperative Eckardt scoring and manometry, supporting go/no-go decisions in preclinical advancement.
Pipeline & Workflow Integration
The method fits within the discovery-to-preclinical continuum by providing a reliable model for assessing target engagement in esophageal motility disorders, where functional validation of muscular inhibition is a key endpoint.
- Discovery Biology: Supports hypothesis testing on sphincter pressure regulation and neuromuscular signaling pathways via precise muscular dissection.
- Screening: Delivers quantifiable tissue readiness through methylene blue-enhanced submucosal visualization, improving tunnel integrity assessment.
- Analytics: Generates measurable outcomes including Eckardt scores, lower esophageal sphincter pressure, and integrated relaxation pressure for comparative analysis.
- Translational Research: Connects mechanistic intervention to functional recovery, aligning with biomarker-driven advancement criteria in preclinical models.
- Enterprise Reuse: Establishes a reusable procedural framework for training and model standardization across gastrointestinal research programs.
Operational & Enterprise Impact
- Scientific Value: Improves target validation confidence by enabling selective, layer-specific myotomy with reduced off-target tissue injury.
- Operational Value: Enhances reproducibility through integrated dissection and coagulation, minimizing operator-dependent variability.
- Strategic Value: De-risks early-stage investment by reducing complications during model development, supporting faster iteration in preclinical screening.
- Portfolio Impact: Informs risk-adjusted progression by providing objective functional endpoints (e.g., Eckardt score ≤1) linked to therapeutic efficacy.
Implementation Considerations
- Requires endoscopic proficiency in tissue grasping and plane dissection to leverage the scissor-type knife’s accuracy benefits.
- Dependent on standard endoscopic platforms with saline-methylene blue injection capability for submucosal visualization.
- Necessitates cross-team standardization between endoscopy and surgical teams for consistent mucosal closure and bleeding assessment.
- Adaptation considerations include varying esophageal wall thickness and fibrosis levels, which may affect dissection plane stability.
- Practical limitation: Device effectiveness may be reduced in severely tortuous or sigmoid esophagus anatomy, as noted in one clinical case.
