Innovations and brief communications
Jet injection of dyed saline facilitates efficient peroral endoscopic myotomy
Authors
Mouen A. Khashab1, Ahmed A. Messallam1, Payal Saxena1, Vivek Kumbhari1, Ernesto Ricourt1, Gerard Aguila1, Bani Chander Roland1, Ellen Stein1, Monica Nandwani1, Haruhiro Inoue2, John O. Clarke1
Institutions
1
submitted 16. June 2013 accepted after revision 17. October 2013
Background and study aims: Peroral endoscopic myotomy (POEM) is technically challenging and time consuming. Repeated injection of dyed saline during tunneling is performed to enhance the demarcation between the submucosal layer and the muscularis propria. This process requires exchanging the knife for a catheter to spray dyed saline and is time consuming. This study aimed to describe a new method of injecting dyed saline through an integrated water jet channel during POEM. Patients and methods: POEM was performed using a triangular tip knife. Repeated jet injection of saline mixed with indigo carmine was performed whenever the submucosal dissection plane became unclear.
Results: The study cohort consisted of nine patients (8 achalasia, 1 Jackhammer esophagus). All procedures were technically feasible and successful without any complications and resulted in the patients’ Eckhardt’s scores returning to normal. The mean submucosal tunnel length was 13.3 cm and the mean myotomy length was 9.9 cm. The mean procedure time was 127 minutes. Conclusion: The modified POEM technique with use of jet injection of dyed saline is simple and may render POEM easier and more efficient than the standard dissection method.
Introduction
neation of submucosal tissue and precise identification of mucosal, submucosal, and muscularis layers. Injury to deeper layers risks full-thickness perforation, mediastinitis, sepsis, injury to mediastinal structures, and pneumothorax/pneumomediastinum. Expert operators recommend repeated injection of dyed saline (e. g. saline mixed with indigo carmine or methylene blue) during tunneling to enhance the demarcation between the submucosal layer and muscularis propria [12]. In our experience, this is an essential practice to ensure the safety of the procedure. Injection of dyed saline is typically delivered by blunt injection via a catheter introduced through the therapeutic channel of a gastroscope. This process usually requires exchanging the ESD knife for a catheter in order to spray the dyed saline. An average of 11 exchanges are required per procedure [13], which adds complexity to the procedure and prolongs procedure times. Any method that simplifies the steps associated with POEM and decreases procedure time may help to proliferate its use. We here describe a new method of injecting dyed saline through an integrated water jet channel.
Bibliography DOI http://dx.doi.org/ 10.1055/s-0033-1359024 Published online: 11.12.2013 Endoscopy 2014; 46: 298–301 © Georg Thieme Verlag KG Stuttgart · New York ISSN 0013-726X Corresponding author Mouen A. Khashab, MD Department of Medicine and Division of Gastroenterology and Hepatology The Johns Hopkins Hospital 1800 Orleans St, Suite 7125 B Baltimore, MD 21205 USA Fax: +1-410-614-0231 [email protected]
Department of Medicine and Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA 2 Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
!
With the advent of natural orifice transluminal endoscopic surgery [1, 2] and continuing improvement of endoscopic devices, therapeutic endoscopy has moved from the lumen or “first” space, to the peritoneal cavity or “second space.” As previously described by Khashab and Pasricha, we have now entered the era of the intramural or “third space” with the recent developments in the field of submucosal endoscopy [3]. Peroral endoscopic myotomy (POEM) was first described in a swine model [4]; 5 years later, more than 3000 procedures in humans have been performed in several centers across the world as POEM become another treatment modality for achalasia. Initial clinical data from Asia, Europe, and the USA have demonstrated the effectiveness and safety of this procedure when performed by experienced endoscopists [5 – 11]. POEM is technically challenging and time consuming. Submucosal tunneling is an integral part of the procedure and involves dissection of submucosal fibers using endoscopic submucosal dissection (ESD) knives. This requires accurate deli-
Khashab Mouen A et al. Dyed saline injection facilitates efficient POEM … Endoscopy 2014; 46: 298–301
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
298
Innovations and brief communications
Methods
Up
!
Light-Guide Lens
Air/Water Nozzle Auxiliary Water Channel Right
Left
Objective Lens Instrument Channel Outlet
Down
Fig. 1 Schematic drawing of the tip of an endoscope with dedicated auxiliary water channel, which permits jet injection of dyed saline during submucosal tunneling while concomitantly using the therapeutic channel for dissection and hemostasis.
Fig. 2 Endoscope setup for jet injection of dyed saline. One bottle of saline and a second bottle of saline mixed with indigo carmine are directly connected to the water jet channel via a stopcock. The former is used to clear the endoscopic view while the latter is used for staining submucosal fibers during tunneling.
Results
Discussion
!
!
A total of nine consecutive patients (mean age 38 years, five females) with achalasia or spastic esophageal disorder underwent POEM procedures at our center using the above described technique with jet injection of dyed saline. Submucosal dissection and endoscopic myotomy were performed using the TT knife. De" Table 1. The mographic and procedural details are listed in ● mean Eckhardt score was 8. All procedures were technically successful without any early or long term complications. There was no breach to the mucosal layer during any procedure. An esophagram was obtained on all patients on postoperative day 1 and no leaks were identified in any patient. All patients were able to commence liquid diet on postoperative day 1, soft diet on postoperative day 1 or 2, and solid meals 2 weeks later. Dysphagia resolved in all patients with a mean postprocedure Eckhardt score of 1. The mean submucosal tunnel length was 13.3 cm and the mean myotomy length was 9.9 cm. The mean procedure time was 127 minutes (which included time to cleanse the esophagus and perform EndoFLIP [Crospon, Carlsbad, California, USA] measurements in the last three patients).
Successful jet injection of dyed saline for staining submucosal fibers during POEM was successful in all nine patients in the current study. The mean procedure time of 127 minutes was in line with other reported studies [5 – 7]. A mean procedure time of 126 minutes was reported by Inoue et al. [5]. Most POEM operators use a TT knife to dissect the submucosal layer and also to divide circular muscle [5, 9 – 12]. The use of a TT knife with an electrosurgical energy generator (VIO 300 D, ERBE) enables a spray-coagulation mode with noncontact tissue dissection. Spray coagulation enables the submucosal dissection during tunnel creation to be performed more easily, faster, and with less
Video 1 Demonstration of the jet injection of dyed saline through the dedicated endoscope channel to facilitate submucosal tunneling during peroral endoscopic myotomy. online content including video sequences viewable at: www.thieme-connect.de
Khashab Mouen A et al. Dyed saline injection facilitates efficient POEM … Endoscopy 2014; 46: 298–301
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
A high definition gastroscope (GIF-HQ190; Olympus, Tokyo, Japan), fitted with a straight cap with an outer length of 4 mm (D-201 – 11804, Olympus), was used. This gastroscope has a slim tip diameter of 9.2 mm and features an integrated water jet chan" Fig. 1). One bottle of saline and a second bottle of saline nel (● mixed with indigo carmine were directly connected to the water " Fig. 2). Separate foot paddles conjet channel via a stopcock (● " Fig. 3). trolled each bottle (● Carbon dioxide insufflation was used throughout the procedures and intravenous antibiotics were administered. The lower esophageal sphincter (LES) was identified. POEM was then performed as previously described [5]. Briefly, a submucosal bleb was created in the mid esophagus using saline and 0.25 % indigo carmine solution. A 2-cm longitudinal mucosal incision was made with a triangular tip (TT) knife (KD 640 L, Olympus) using dry cut mode at 50 W on effect 3 (ERBE, Tübingen, Germany). The endoscope was then maneuvered into the submucosal space and the TT knife was used to dissect the submucosal fibers using spray coagulation mode at 50 W on effect 2. Repeated jet injection of saline mixed with indigo carmine was performed to enhance the demarcation between the submucosal layer and muscularis propria whenever the submucosal dissection plane became un" Video 1). clear (● Care was taken with orientation of the endoscope to ensure the mucosal layer was not injured during dissection as the submucosal tunnel was extended, passing the LES and 2 cm into the proximal stomach. Subsequently, myotomy of the inner circular muscle bundles was performed starting 2 cm distal to the mucosal entry point. The sharp tip of the TT knife was used to catch single circular muscle bundles, lift them toward the tunnel, followed by cutting with spray coagulation current at 50 W on effect 2. Larger vessels in the submucosa were coagulated using the Coagrasper (Olympus) in soft coagulation mode at 80 W on effect 5. Mucosal entry was then closed using endoscopic clips.
299
Innovations and brief communications
Fig. 3 Setup for jet injection of dyed saline. Separate foot paddles control injection of either pure saline for optimizing visual field or dyed saline for submucosal tunneling.
Table 1
Patient and procedural characteristics of study cohort.
Patient no.
Age, years
Sex
Esophageal motility
Submucosal tunnel
Myotomy length,
disorder*
length, cm
cm
Procedure time, minutes
Achalasia type III
19
15
164
1
63
Female
2
49
Female
Achalasia type II
12
8
140
3
32
Male
Achalasia type II
10
7
113
4
22
Male
Achalasia type II
10
7
110
5
39
Female
Achalasia type I
12
9
150
6
39
Male
Achalasia type II
11
8
120
7
27
Male
Achalasia type I
11
8
128
8
24
Female
Achalasia type II
12
8
131
9
50
Female
Jackhammer esophagus
23
19
90
* Achalasia subtype was defined according to the Chicago classification [14].
bleeding [12]. The shortcoming of the TT knife is that it does not allow injection of dyed saline to stain submucosal fibers. This results in frequent exchange of devices and prolongs procedure times. Exchange of the TT knife to an injection needle for blunt injection of dyed saline is the method most commonly reported for staining of submucosal fibers to enhance the demarcation between the submucosal layer and muscularis propria [5 – 7]. Direct jet injection of dyed saline through the dedicated channel of the gastroscope results in adequate, consistent, and reliable staining of submucosal fibers, which renders submucosal dissection accurate, efficient, and safe. Use of the HybridKnife (ERBE) can overcome the limitations of the TT knife as it allows for high pressure water-jet for needleless submucosal injection and electrosurgical interventions such as submucosal tunneling and endoscopic myotomy of inner circular muscle bundles. One randomized controlled trial presented in abstract form showed that the HybridKnife led to significantly shorter operative times compared with the standard technique using the TT knife [13]. This was mainly due to a significant decrease in the mean number of instrument exchanges needed during the procedure (0.92 vs. 11.1) [13]. Nonetheless, most POEM operators worldwide use the TT knife for both submucosal tunneling and endoscopic myotomy. In addition, the HybridKnife
does not permit spray-coagulation mode with noncontact tissue dissection. The use of our simple technique described here offers the advantage of fewer instrument exchanges with continued use of the TT knife, which has the advantage of allowing for spray coagulation. A prerequisite to the technique is availability of a gastroscope with a dedicated water jet channel. The GIF-HQ190 (Olympus) was used for this purpose. Another advantage of this endoscope is its slim tip diameter of 9.2 mm, which allows for better manipulation inside the narrow submucosal tunnel. In addition, the dual focus feature of the GIF-HQ190 endoscope allows the endoscopist to select from two focus settings (near field or normal field), which aids in precise identification of the layers, including differentiating inner circular muscle fibers from outer longitudinal ones. Other gastroscopes with dedicated water jet channels are also available and include the GIF-H180 J gastroscope (Olympus), and EG2990i and EG2990k gastroscopes (Pentax Medical Corp., Montvale, New Jersey, USA). We also believe that a dedicated water channel is an essential feature for safe POEM procedures as it ensures a clear endoscopic view, especially during bleeding inside the narrow submucosal tunnel with limited visibility and maneuverability, while permitting dedicated use of the therapeutic channel for hemostasis.
Khashab Mouen A et al. Dyed saline injection facilitates efficient POEM … Endoscopy 2014; 46: 298–301
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
300
In conclusion, the modified POEM technique with use of jet injection of dyed saline is simple and may render POEM easier and more efficient. A comparative trial of POEM performed using jet injection vs. standard technique would be of interest. Competing interests: Dr. Khashab is a consultant for Boston Scientific and Olympus America and has received research support from Cook Medical. All other authors have no relevant disclosures.
References 1 Khashab MA, Kalloo AN. NOTES: current status and new horizons. Gastroenterology 2012; 142: 704 – 710 2 Khashab MA, Kalloo AN. Critical analysis of hot topics in NOTES. Nat Rev Gastroenterol Hepatol 2012; 8: 565 – 572 3 Khashab MA, Pasricha PJ. Conquering the third space: challenges and opportunities for diagnostic and therapeutic endoscopy. Gastrointest Endosc 2013; 77: 146 – 148 4 Pasricha PJ, Hawari R, Ahmed I et al. Submucosal endoscopic esophageal myotomy: a novel experimental approach for the treatment of achalasia. Endoscopy 2007; 39: 761 – 764 5 Inoue H, Minami H, Kobayashi Y et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy 2010; 42: 265 – 271 6 von Renteln D, Inoue H, Minami H et al. Peroral endoscopic myotomy for the treatment of achalasia: a prospective single center study. Am J Gastroenterol 2012; 107: 411 – 417
7 Costamagna G, Marchese M, Familiari P et al. Peroral endoscopic myotomy (POEM) for oesophageal achalasia: preliminary results in humans. Dig Liver Dis 2012; 44: 827 – 832 8 Maselli R, Inoue H, Misawa M et al. Peroral endoscopic myotomy (POEM) in a 3-year-old girl with severe growth retardation, achalasia, and Down syndrome. Endoscopy 2012; 44: E285 – E287 9 Kurian AA, Dunst CM, Sharata A et al. Peroral endoscopic esophageal myotomy: defining the learning curve. Gastrointest Endosc 2013; 77: 719 – 725 10 Swanstrom LL, Rieder E, Dunst CM. A stepwise approach and early clinical experience in peroral endoscopic myotomy for the treatment of achalasia and esophageal motility disorders. J Am Coll Surg 2011; 213: 751 – 756 11 Saxena P, Chavez YH, Kord Valeshabad A et al. An alternative method for mucosal flap closure during POEM using an over-the-scope clipping device (with video). Endoscopy 2013; 45: 579 – 581 12 Inoue H, Tianle KM, Ikeda H et al. Peroral endoscopic myotomy for esophageal achalasia: technique, indication, and outcomes. Thorac Surg Clin 2011; 21: 519 – 525 13 Pinghong Z, Liqing Y, Mingyan C et al. Water-jet assisted peroral endoscopic myotomy (POEM) in comparison to conventional endoscopic myotomy technique for treatment of esophageal achalasia. Gastrointest Endosc 2012; 75: AB160 – AB161 14 Bredenoord AJ, Fox M, Kahrilas PJ et al. Chicago classification criteria of esophageal motility disorders defined in high resolution esophageal pressure topography. Neurogastroenterol Motil 2012; 24: 57 – 65
Khashab Mouen A et al. Dyed saline injection facilitates efficient POEM … Endoscopy 2014; 46: 298–301
301
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Innovations and brief communications
Copyright of Endoscopy is the property of Georg Thieme Verlag Stuttgart and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Jet injection of dyed saline facilitates efficient peroral endoscopic myotomy
Authors
Mouen A. Khashab1, Ahmed A. Messallam1, Payal Saxena1, Vivek Kumbhari1, Ernesto Ricourt1, Gerard Aguila1, Bani Chander Roland1, Ellen Stein1, Monica Nandwani1, Haruhiro Inoue2, John O. Clarke1
Institutions
1
submitted 16. June 2013 accepted after revision 17. October 2013
Background and study aims: Peroral endoscopic myotomy (POEM) is technically challenging and time consuming. Repeated injection of dyed saline during tunneling is performed to enhance the demarcation between the submucosal layer and the muscularis propria. This process requires exchanging the knife for a catheter to spray dyed saline and is time consuming. This study aimed to describe a new method of injecting dyed saline through an integrated water jet channel during POEM. Patients and methods: POEM was performed using a triangular tip knife. Repeated jet injection of saline mixed with indigo carmine was performed whenever the submucosal dissection plane became unclear.
Results: The study cohort consisted of nine patients (8 achalasia, 1 Jackhammer esophagus). All procedures were technically feasible and successful without any complications and resulted in the patients’ Eckhardt’s scores returning to normal. The mean submucosal tunnel length was 13.3 cm and the mean myotomy length was 9.9 cm. The mean procedure time was 127 minutes. Conclusion: The modified POEM technique with use of jet injection of dyed saline is simple and may render POEM easier and more efficient than the standard dissection method.
Introduction
neation of submucosal tissue and precise identification of mucosal, submucosal, and muscularis layers. Injury to deeper layers risks full-thickness perforation, mediastinitis, sepsis, injury to mediastinal structures, and pneumothorax/pneumomediastinum. Expert operators recommend repeated injection of dyed saline (e. g. saline mixed with indigo carmine or methylene blue) during tunneling to enhance the demarcation between the submucosal layer and muscularis propria [12]. In our experience, this is an essential practice to ensure the safety of the procedure. Injection of dyed saline is typically delivered by blunt injection via a catheter introduced through the therapeutic channel of a gastroscope. This process usually requires exchanging the ESD knife for a catheter in order to spray the dyed saline. An average of 11 exchanges are required per procedure [13], which adds complexity to the procedure and prolongs procedure times. Any method that simplifies the steps associated with POEM and decreases procedure time may help to proliferate its use. We here describe a new method of injecting dyed saline through an integrated water jet channel.
Bibliography DOI http://dx.doi.org/ 10.1055/s-0033-1359024 Published online: 11.12.2013 Endoscopy 2014; 46: 298–301 © Georg Thieme Verlag KG Stuttgart · New York ISSN 0013-726X Corresponding author Mouen A. Khashab, MD Department of Medicine and Division of Gastroenterology and Hepatology The Johns Hopkins Hospital 1800 Orleans St, Suite 7125 B Baltimore, MD 21205 USA Fax: +1-410-614-0231 [email protected]
Department of Medicine and Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA 2 Digestive Disease Center, Showa University Northern Yokohama Hospital, Yokohama, Japan
!
With the advent of natural orifice transluminal endoscopic surgery [1, 2] and continuing improvement of endoscopic devices, therapeutic endoscopy has moved from the lumen or “first” space, to the peritoneal cavity or “second space.” As previously described by Khashab and Pasricha, we have now entered the era of the intramural or “third space” with the recent developments in the field of submucosal endoscopy [3]. Peroral endoscopic myotomy (POEM) was first described in a swine model [4]; 5 years later, more than 3000 procedures in humans have been performed in several centers across the world as POEM become another treatment modality for achalasia. Initial clinical data from Asia, Europe, and the USA have demonstrated the effectiveness and safety of this procedure when performed by experienced endoscopists [5 – 11]. POEM is technically challenging and time consuming. Submucosal tunneling is an integral part of the procedure and involves dissection of submucosal fibers using endoscopic submucosal dissection (ESD) knives. This requires accurate deli-
Khashab Mouen A et al. Dyed saline injection facilitates efficient POEM … Endoscopy 2014; 46: 298–301
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
298
Innovations and brief communications
Methods
Up
!
Light-Guide Lens
Air/Water Nozzle Auxiliary Water Channel Right
Left
Objective Lens Instrument Channel Outlet
Down
Fig. 1 Schematic drawing of the tip of an endoscope with dedicated auxiliary water channel, which permits jet injection of dyed saline during submucosal tunneling while concomitantly using the therapeutic channel for dissection and hemostasis.
Fig. 2 Endoscope setup for jet injection of dyed saline. One bottle of saline and a second bottle of saline mixed with indigo carmine are directly connected to the water jet channel via a stopcock. The former is used to clear the endoscopic view while the latter is used for staining submucosal fibers during tunneling.
Results
Discussion
!
!
A total of nine consecutive patients (mean age 38 years, five females) with achalasia or spastic esophageal disorder underwent POEM procedures at our center using the above described technique with jet injection of dyed saline. Submucosal dissection and endoscopic myotomy were performed using the TT knife. De" Table 1. The mographic and procedural details are listed in ● mean Eckhardt score was 8. All procedures were technically successful without any early or long term complications. There was no breach to the mucosal layer during any procedure. An esophagram was obtained on all patients on postoperative day 1 and no leaks were identified in any patient. All patients were able to commence liquid diet on postoperative day 1, soft diet on postoperative day 1 or 2, and solid meals 2 weeks later. Dysphagia resolved in all patients with a mean postprocedure Eckhardt score of 1. The mean submucosal tunnel length was 13.3 cm and the mean myotomy length was 9.9 cm. The mean procedure time was 127 minutes (which included time to cleanse the esophagus and perform EndoFLIP [Crospon, Carlsbad, California, USA] measurements in the last three patients).
Successful jet injection of dyed saline for staining submucosal fibers during POEM was successful in all nine patients in the current study. The mean procedure time of 127 minutes was in line with other reported studies [5 – 7]. A mean procedure time of 126 minutes was reported by Inoue et al. [5]. Most POEM operators use a TT knife to dissect the submucosal layer and also to divide circular muscle [5, 9 – 12]. The use of a TT knife with an electrosurgical energy generator (VIO 300 D, ERBE) enables a spray-coagulation mode with noncontact tissue dissection. Spray coagulation enables the submucosal dissection during tunnel creation to be performed more easily, faster, and with less
Video 1 Demonstration of the jet injection of dyed saline through the dedicated endoscope channel to facilitate submucosal tunneling during peroral endoscopic myotomy. online content including video sequences viewable at: www.thieme-connect.de
Khashab Mouen A et al. Dyed saline injection facilitates efficient POEM … Endoscopy 2014; 46: 298–301
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
A high definition gastroscope (GIF-HQ190; Olympus, Tokyo, Japan), fitted with a straight cap with an outer length of 4 mm (D-201 – 11804, Olympus), was used. This gastroscope has a slim tip diameter of 9.2 mm and features an integrated water jet chan" Fig. 1). One bottle of saline and a second bottle of saline nel (● mixed with indigo carmine were directly connected to the water " Fig. 2). Separate foot paddles conjet channel via a stopcock (● " Fig. 3). trolled each bottle (● Carbon dioxide insufflation was used throughout the procedures and intravenous antibiotics were administered. The lower esophageal sphincter (LES) was identified. POEM was then performed as previously described [5]. Briefly, a submucosal bleb was created in the mid esophagus using saline and 0.25 % indigo carmine solution. A 2-cm longitudinal mucosal incision was made with a triangular tip (TT) knife (KD 640 L, Olympus) using dry cut mode at 50 W on effect 3 (ERBE, Tübingen, Germany). The endoscope was then maneuvered into the submucosal space and the TT knife was used to dissect the submucosal fibers using spray coagulation mode at 50 W on effect 2. Repeated jet injection of saline mixed with indigo carmine was performed to enhance the demarcation between the submucosal layer and muscularis propria whenever the submucosal dissection plane became un" Video 1). clear (● Care was taken with orientation of the endoscope to ensure the mucosal layer was not injured during dissection as the submucosal tunnel was extended, passing the LES and 2 cm into the proximal stomach. Subsequently, myotomy of the inner circular muscle bundles was performed starting 2 cm distal to the mucosal entry point. The sharp tip of the TT knife was used to catch single circular muscle bundles, lift them toward the tunnel, followed by cutting with spray coagulation current at 50 W on effect 2. Larger vessels in the submucosa were coagulated using the Coagrasper (Olympus) in soft coagulation mode at 80 W on effect 5. Mucosal entry was then closed using endoscopic clips.
299
Innovations and brief communications
Fig. 3 Setup for jet injection of dyed saline. Separate foot paddles control injection of either pure saline for optimizing visual field or dyed saline for submucosal tunneling.
Table 1
Patient and procedural characteristics of study cohort.
Patient no.
Age, years
Sex
Esophageal motility
Submucosal tunnel
Myotomy length,
disorder*
length, cm
cm
Procedure time, minutes
Achalasia type III
19
15
164
1
63
Female
2
49
Female
Achalasia type II
12
8
140
3
32
Male
Achalasia type II
10
7
113
4
22
Male
Achalasia type II
10
7
110
5
39
Female
Achalasia type I
12
9
150
6
39
Male
Achalasia type II
11
8
120
7
27
Male
Achalasia type I
11
8
128
8
24
Female
Achalasia type II
12
8
131
9
50
Female
Jackhammer esophagus
23
19
90
* Achalasia subtype was defined according to the Chicago classification [14].
bleeding [12]. The shortcoming of the TT knife is that it does not allow injection of dyed saline to stain submucosal fibers. This results in frequent exchange of devices and prolongs procedure times. Exchange of the TT knife to an injection needle for blunt injection of dyed saline is the method most commonly reported for staining of submucosal fibers to enhance the demarcation between the submucosal layer and muscularis propria [5 – 7]. Direct jet injection of dyed saline through the dedicated channel of the gastroscope results in adequate, consistent, and reliable staining of submucosal fibers, which renders submucosal dissection accurate, efficient, and safe. Use of the HybridKnife (ERBE) can overcome the limitations of the TT knife as it allows for high pressure water-jet for needleless submucosal injection and electrosurgical interventions such as submucosal tunneling and endoscopic myotomy of inner circular muscle bundles. One randomized controlled trial presented in abstract form showed that the HybridKnife led to significantly shorter operative times compared with the standard technique using the TT knife [13]. This was mainly due to a significant decrease in the mean number of instrument exchanges needed during the procedure (0.92 vs. 11.1) [13]. Nonetheless, most POEM operators worldwide use the TT knife for both submucosal tunneling and endoscopic myotomy. In addition, the HybridKnife
does not permit spray-coagulation mode with noncontact tissue dissection. The use of our simple technique described here offers the advantage of fewer instrument exchanges with continued use of the TT knife, which has the advantage of allowing for spray coagulation. A prerequisite to the technique is availability of a gastroscope with a dedicated water jet channel. The GIF-HQ190 (Olympus) was used for this purpose. Another advantage of this endoscope is its slim tip diameter of 9.2 mm, which allows for better manipulation inside the narrow submucosal tunnel. In addition, the dual focus feature of the GIF-HQ190 endoscope allows the endoscopist to select from two focus settings (near field or normal field), which aids in precise identification of the layers, including differentiating inner circular muscle fibers from outer longitudinal ones. Other gastroscopes with dedicated water jet channels are also available and include the GIF-H180 J gastroscope (Olympus), and EG2990i and EG2990k gastroscopes (Pentax Medical Corp., Montvale, New Jersey, USA). We also believe that a dedicated water channel is an essential feature for safe POEM procedures as it ensures a clear endoscopic view, especially during bleeding inside the narrow submucosal tunnel with limited visibility and maneuverability, while permitting dedicated use of the therapeutic channel for hemostasis.
Khashab Mouen A et al. Dyed saline injection facilitates efficient POEM … Endoscopy 2014; 46: 298–301
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
300
In conclusion, the modified POEM technique with use of jet injection of dyed saline is simple and may render POEM easier and more efficient. A comparative trial of POEM performed using jet injection vs. standard technique would be of interest. Competing interests: Dr. Khashab is a consultant for Boston Scientific and Olympus America and has received research support from Cook Medical. All other authors have no relevant disclosures.
References 1 Khashab MA, Kalloo AN. NOTES: current status and new horizons. Gastroenterology 2012; 142: 704 – 710 2 Khashab MA, Kalloo AN. Critical analysis of hot topics in NOTES. Nat Rev Gastroenterol Hepatol 2012; 8: 565 – 572 3 Khashab MA, Pasricha PJ. Conquering the third space: challenges and opportunities for diagnostic and therapeutic endoscopy. Gastrointest Endosc 2013; 77: 146 – 148 4 Pasricha PJ, Hawari R, Ahmed I et al. Submucosal endoscopic esophageal myotomy: a novel experimental approach for the treatment of achalasia. Endoscopy 2007; 39: 761 – 764 5 Inoue H, Minami H, Kobayashi Y et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy 2010; 42: 265 – 271 6 von Renteln D, Inoue H, Minami H et al. Peroral endoscopic myotomy for the treatment of achalasia: a prospective single center study. Am J Gastroenterol 2012; 107: 411 – 417
7 Costamagna G, Marchese M, Familiari P et al. Peroral endoscopic myotomy (POEM) for oesophageal achalasia: preliminary results in humans. Dig Liver Dis 2012; 44: 827 – 832 8 Maselli R, Inoue H, Misawa M et al. Peroral endoscopic myotomy (POEM) in a 3-year-old girl with severe growth retardation, achalasia, and Down syndrome. Endoscopy 2012; 44: E285 – E287 9 Kurian AA, Dunst CM, Sharata A et al. Peroral endoscopic esophageal myotomy: defining the learning curve. Gastrointest Endosc 2013; 77: 719 – 725 10 Swanstrom LL, Rieder E, Dunst CM. A stepwise approach and early clinical experience in peroral endoscopic myotomy for the treatment of achalasia and esophageal motility disorders. J Am Coll Surg 2011; 213: 751 – 756 11 Saxena P, Chavez YH, Kord Valeshabad A et al. An alternative method for mucosal flap closure during POEM using an over-the-scope clipping device (with video). Endoscopy 2013; 45: 579 – 581 12 Inoue H, Tianle KM, Ikeda H et al. Peroral endoscopic myotomy for esophageal achalasia: technique, indication, and outcomes. Thorac Surg Clin 2011; 21: 519 – 525 13 Pinghong Z, Liqing Y, Mingyan C et al. Water-jet assisted peroral endoscopic myotomy (POEM) in comparison to conventional endoscopic myotomy technique for treatment of esophageal achalasia. Gastrointest Endosc 2012; 75: AB160 – AB161 14 Bredenoord AJ, Fox M, Kahrilas PJ et al. Chicago classification criteria of esophageal motility disorders defined in high resolution esophageal pressure topography. Neurogastroenterol Motil 2012; 24: 57 – 65
Khashab Mouen A et al. Dyed saline injection facilitates efficient POEM … Endoscopy 2014; 46: 298–301
301
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Innovations and brief communications
Copyright of Endoscopy is the property of Georg Thieme Verlag Stuttgart and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
