Use of the Scissor-Type Knife During the Peroral Endoscopy Myotomy Procedure for the Treatment of Achalasia

Summary

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.

Abstract

Peroral endoscopic myotomy (POEM) is one of the first-line treatment modalities along with pneumatic dilation and Heller myotomy for patients with achalasia. Endoscopists, especially trainees during the learning phase, commonly face difficulty in tissue plane dissection and selective myotomy while working near the esophagogastric junction, with increased risks of inadvertent injury, unexpected bleeding, and inadequate myotomy. To minimize the technical difficulty and improve the safety of 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. The standard techniques used with the scissor-type knife involve grasping the target tissue, and then dissection or coagulation. The confirmation of the cutting line after grasping improves the accuracy and reliability of dissection, which is particularly useful for the selective myotomy of the internal circular muscle. Meanwhile, the scissor-type knife provides enhanced hemostatic capability and enables hemostasis and pre-coagulation without the device exchange for hemostatic forceps. Evaluation of the clinical outcomes in three patients who successfully received POEM using the scissor-type knife revealed no perioperative adverse events. At the 3-month follow-up, all patients achieved clinical success with postoperative Eckardt scores ranging from 0 to 1. In conclusion, the use of a scissor-type knife could minimize the technical difficulty and improve the safety of the POEM procedures, which may be suitable for trainees during the learning phase.

Introduction

Peroral endoscopic myotomy (POEM) has gained worldwide acceptance as one of the first-line treatment modalities along with pneumatic dilation and Heller myotomy for patients with achalasia¹. To date, most POEM procedures have been confined to a few high-volume, specialized centers. Previous studies have shown that even operators skilled in laparoscopy or endoscopy have a steep learning curve when they are beginning to perform POEM and a higher volume of cases is required to manage challenging situations and prevent adverse events^2,3. During POEM procedures, endoscopic needle-knives are ....

Protocol

The protocol was conducted in accordance with the Declaration of Helsinki and the protocol was approved by the Institutional Review Board at the First Affiliated Hospital of Sun Yat-sen University.

1. Patient selection

1. Diagnose achalasia by clinical manifestations and diagnostic testing (barium esophagram, high-resolution manometry (HRM), and upper endoscopy)¹⁰: the presence of symptoms such as dysphagia, regurgitation, chest pain, and weight loss; the "bird's-beak" appearance on barium esophagram; impaired relaxation of the lower esophageal sphincter and absent peristalsis on....

Results

Compared with the needle-type knife, the scissor-type knife enables coagulation and dissection after grasping the target tissue. Meanwhile, the scissor-type knife is equipped with an enhanced hemostatic capability similar to hemostatic forceps and insulated coating external of the two blades (Table 1). 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.......

Discussion

As an evolving endoscopic surgical treatment for achalasia, POEM requires both advanced endoscopic skills and knowledge of surgical anatomy. A recent study demonstrated that POEM comes with a considerable learning curve that increases the risk of technical failure, adverse events, and clinical failure². Endoscopists, especially trainees who have not completed their learning phase, commonly face difficulty in accurate manipulations of the endoscopic knife while working near the EGJ with limited wor.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Electrogenerator	ERBE Elektromedizin	VIO 200S
Endoclip	Micro-Tech (Nanjing)	ROCC-D-26-195-C
Endoscope	Olympus	GIF-H260
Injection Needle	Olympus	NM-400L-0423
Stag Beetle Knife Jr	Sumitomo Bakelite	MD-47703W
Transparent Distal Cap	Olympus	D-201-11804