A simple method to determine the proper length of the gastric myotomy during peroral endoscopic myotomy for achalasia

Abstract

Peroral endoscopic myotomy (POEM) was first performed in 2008 by Inoue and since then has been used widely, with noninferiority to Heller's myotomy [1]. A critical step during POEM is ensuring an appropriate length of the gastric myotomy (2-2.5 cm), as a short myotomy can lead to a lack of response, and if too long, a higher incidence of moderate reflux esophagitis may occur without improving clinical efficacy [2, 3]. Various methods of verifying the proper extent of the tunnel have been described: use of a double scope for transillumination at the gastric cardia [4]; identification of the two penetrating vessels during posterior POEM [5]; distance from incisors (insertion depth); intraprocedural X-ray; or injection of indocyanine green into the submucosa on the gastric E-Videos Video 1 A simple method to ensure a 2-cm gastric myotomy during peroral endoscopic myotomy. ▶ Fig. 1 The tip of the scope is positioned at the esophagogastric junction, with the knife placed outside the working channel, just far enough to see the tip in the screen. With the help of a ruler, a mark is placed on the knife 2 cm from the endoscope channel.

The “furrow sign” in confirming proper gastric extent and direction of the myotomy at the end of peroral endoscopic myotomy

“…Conversely, excessive length can result in a higher incidence of moderate reflux esophagitis without enhancing clinical effectiveness 2 3 . While various landmarks and methods guide the proper extent of the tunnel 4 5 , a straightforward approach to confirm the end of the myotomy is lacking.…”

“…Conversely, excessive length can result in a higher incidence of moderate reflux esophagitis without enhancing clinical effectiveness [2,3]. While various landmarks and methods guide the proper extent of the tunnel [4,5], a straightforward approach to confirm the end of the myotomy is lacking. Herein, we introduce the concept of the "furrow sign," characterized by a mucosal depression over a muscular defect in the wall post-myotomy.…”

The "Furrow sign" to confirm proper gastric extent and direction of the myotomy at the end of POEM

“…Abstract Text Aims: to describe a simple and novel sign to confirm the direction and proper length of gastric myotomy at the end of POEM procedure 1 2 3 4 .…”