Tu1209 EARLY EXPERIENCE USING A SCISSOR-TYPE KNIFE IN PERORAL ENDOSCOPIC MYOTOMY

Abstract

Per oral endoscopic myotomy (POEM) has been developed to offer a less-invasive option for the management of patients with achalasia. Traditionally, the procedure is performed using a needle-type knife and any bleeding encountered is treated using coagulation graspers. The major risks of POEM procedure are bleeding and perforation. A novel scissor-type knife (SB knife, Olympus, Tokyo, Japan) works by grasping tissue and then simultaneously coagulating and cutting through the tissue. Currently, this device is recommended for endoscopic submucosal dissection and has not been reported for POEM procedure. To evaluate the safety and efficacy of a scissor-type knife for submucosal tunneling and myotomy during POEM procedure. We performed a prospective observational study on 4 patients who presented for evaluation of recently diagnosed achalasia and who underwent POEM procedure between September 12 and October 31, 2017. All 4 patients had upper endoscopy and EUS to rule out pseudoachalasia, and high-resolution manometry and barium esophogram were performed to confirm the diagnosis. Each patient underwent POEM procedure using a needle-type knife to create the mucosal incision followed by the scissor-type knife to perform submucosal tunneling and myotomy (see Image 1). Closure of the mucosotomy was done using endoscopic suturing. Impedance planimetry was performed before and after each procedure. All patients were discharged home within 24 hours after a barium esophogram revealed no leak. All 4 POEM procedures were performed without complication by a single endoscopist (KC). Any bleeding vessel encountered during the procedures was treated using the scissor-type knife. On average, there was only 1 episode of spontaneous bleeding per case. Tunneling time, myotomy time, and distensibility index during impedance planimetry before and after the procedure is displayed in Table 1. These 4 cases represent the first reported use of scissors-type knife during POEM procedure. Submucosal tissue and blood vessels can be coagulated and cut simultaneously which may result in less spontaneous bleeding and more efficient management when bleeding does occur. Full thickness myotomy can be performed accurately and efficiently. Rates of perforation may also be lower with grasping of muscle fibres during myotomy. Further multi-center studies should study the safety and efficacy of the scissor-type knife compared to traditional needle-type knives.Tabled 1Procedural data for POEM procedure using scissor-type knife.PatientAchalasia TypeTunneling time (minutes)Myotomy time (minutes)Spontaneous bleeding episodesPre-POEM distensibility index (mm2/mmHg)Post-POEM distensibility index (mm2/mmHg)A2533220.93.5B3441910.93.5C1311601.65.3D2372510.94.5 Open table in a new tab