VIDEOGIE Todd H. Baron, MD, G. S. Raju, MD, Editors for VideoGIE
New transillumination auxiliary technique for peroral endoscopic myotomy
Figure 1. Peroral endoscopic myotomy by using the transillumination technique. After creating a submucosal tunnel extending to the cardia, we inserted an ultrathin gastroscope through the nose into the stomach and oriented it in a retroflex position. Inset: The insertion depth of the within-the-tunnel endoscope can be determined easily through transillumination, after reducing the light source intensity of the ultrathin gastroscope.
Several landmarks are currently used to identify the correct localization of the cardia during peroral endoscopic myotomy (POEM). However, previously described landmarks are difficult to use and are not accurate, which can result in inadequate length of the myotomy incision. If it is too short, the myotomy can be ineffective and if too long, it may be associated with increased risks of perforation and bleeding. We describe a new transillumination POEM auxiliary technique that enables proper identification of the cardia. After creation of a submucosal tunnel along the distal esophagus and cardia, an ultrathin, 5.9mm gastroscope is inserted through the nose into the gastric lumen. Once inside the stomach, the ultrathin
This video can be viewed directly from the GIE website or by using the QR code and your mobile device. Download a free QR code scanner by searching “QR Scanner” in your mobile device's app store. 544 GASTROINTESTINAL ENDOSCOPY Volume 79, No. 4 : 2014
gastroscope is oriented in a retroflex position with visualization of the cardia. Then, the light intensity of this gastroscope is decreased, enabling correct identification of the within-the-tunnel gastroscope through transillumination. This allows correct assessment of the submucosal tunnel and myotomy lengths. The transillumination POEM auxiliary technique was evaluated in 2 consecutive POEM procedures. It was feasible in both cases and led to extension of the tunnel and myotomy by approximately 2 cm in each patient. In both cases, there was a significant improvement in the manometry pressure, contrast radiograph findings, and symptoms (Eckardt score !3), without major adverse events. In this first description of the transillumination auxiliary technique for POEM, the technique was demonstrated to be fast and easy, enabling precise, safe, and effective myotomy (Fig. 1; Video 1, available online at www. giejournal.org). DISCLOSURE All authors disclosed no financial relationships relevant to this publication. www.giejournal.org
VideoGIE
ACKNOWLEDGMENTS The authors would like to thank Tomas Silva for the video voiceover and the team from Fortifeio (fortifeio.pt) for the laborious and elegant work on Figure 1.
Francisco Baldaque-Silva, MD, Margarida Marques, MD, Filipe Vilas-Boas, MD, João Diogo Maia, MD, Filipa Sá, MD, Guilherme Macedo, MD, PhD, Gastroenterology Department, Centro Hospitalar de São João, Porto, Portugal http://dx.doi.org/10.1016/j.gie.2013.10.023
Read Articles in Press Online Today! Visit www.giejournal.org Gastrointestinal Endoscopy now posts in-press articles online in advance of their appearance in the print edition of the Journal. These articles are available at the Gastrointestinal Endoscopy Web site, www.giejournal.org, by clicking on the “Articles in Press” link, as well as at Elsevier’s ScienceDirect Web site, www.sciencedirect.com. Articles in Press represent the final edited text of articles that are accepted for publication but not yet scheduled to appear in the print journal. They are considered officially published as of the date of Web publication, which means readers can access the information and authors can cite the research months prior to its availability in print. To cite Articles in Press, include the journal title, year, and the article’s Digital Object Identifier (DOI), located in the article footnote. Please visit Gastrointestinal Endoscopy online today to read Articles in Press and stay current on the latest research in the field of gastrointestinal endoscopy.
www.giejournal.org
Volume 79, No. 4 : 2014 GASTROINTESTINAL ENDOSCOPY 545
New transillumination auxiliary technique for peroral endoscopic myotomy
Figure 1. Peroral endoscopic myotomy by using the transillumination technique. After creating a submucosal tunnel extending to the cardia, we inserted an ultrathin gastroscope through the nose into the stomach and oriented it in a retroflex position. Inset: The insertion depth of the within-the-tunnel endoscope can be determined easily through transillumination, after reducing the light source intensity of the ultrathin gastroscope.
Several landmarks are currently used to identify the correct localization of the cardia during peroral endoscopic myotomy (POEM). However, previously described landmarks are difficult to use and are not accurate, which can result in inadequate length of the myotomy incision. If it is too short, the myotomy can be ineffective and if too long, it may be associated with increased risks of perforation and bleeding. We describe a new transillumination POEM auxiliary technique that enables proper identification of the cardia. After creation of a submucosal tunnel along the distal esophagus and cardia, an ultrathin, 5.9mm gastroscope is inserted through the nose into the gastric lumen. Once inside the stomach, the ultrathin
This video can be viewed directly from the GIE website or by using the QR code and your mobile device. Download a free QR code scanner by searching “QR Scanner” in your mobile device's app store. 544 GASTROINTESTINAL ENDOSCOPY Volume 79, No. 4 : 2014
gastroscope is oriented in a retroflex position with visualization of the cardia. Then, the light intensity of this gastroscope is decreased, enabling correct identification of the within-the-tunnel gastroscope through transillumination. This allows correct assessment of the submucosal tunnel and myotomy lengths. The transillumination POEM auxiliary technique was evaluated in 2 consecutive POEM procedures. It was feasible in both cases and led to extension of the tunnel and myotomy by approximately 2 cm in each patient. In both cases, there was a significant improvement in the manometry pressure, contrast radiograph findings, and symptoms (Eckardt score !3), without major adverse events. In this first description of the transillumination auxiliary technique for POEM, the technique was demonstrated to be fast and easy, enabling precise, safe, and effective myotomy (Fig. 1; Video 1, available online at www. giejournal.org). DISCLOSURE All authors disclosed no financial relationships relevant to this publication. www.giejournal.org
VideoGIE
ACKNOWLEDGMENTS The authors would like to thank Tomas Silva for the video voiceover and the team from Fortifeio (fortifeio.pt) for the laborious and elegant work on Figure 1.
Francisco Baldaque-Silva, MD, Margarida Marques, MD, Filipe Vilas-Boas, MD, João Diogo Maia, MD, Filipa Sá, MD, Guilherme Macedo, MD, PhD, Gastroenterology Department, Centro Hospitalar de São João, Porto, Portugal http://dx.doi.org/10.1016/j.gie.2013.10.023
Read Articles in Press Online Today! Visit www.giejournal.org Gastrointestinal Endoscopy now posts in-press articles online in advance of their appearance in the print edition of the Journal. These articles are available at the Gastrointestinal Endoscopy Web site, www.giejournal.org, by clicking on the “Articles in Press” link, as well as at Elsevier’s ScienceDirect Web site, www.sciencedirect.com. Articles in Press represent the final edited text of articles that are accepted for publication but not yet scheduled to appear in the print journal. They are considered officially published as of the date of Web publication, which means readers can access the information and authors can cite the research months prior to its availability in print. To cite Articles in Press, include the journal title, year, and the article’s Digital Object Identifier (DOI), located in the article footnote. Please visit Gastrointestinal Endoscopy online today to read Articles in Press and stay current on the latest research in the field of gastrointestinal endoscopy.
www.giejournal.org
Volume 79, No. 4 : 2014 GASTROINTESTINAL ENDOSCOPY 545
