Peroral Endoscopic Myotomy
During the procedure the endoscope is inserted into the esophagus where an incision or cut is made in the lining of the mucosal esophagus. The doctor uses a special knife on the tip of the endoscope to tunnel through the wall or the submucose of the esophagus. This allows the doctor to access the muscle layers below. Next the myotomy is performed. The doctor uses an endoscopic knife to cut and partially remove the inner circular muscle layer. The muscle layer is partially removed through the last part of the esophagus, the lower esophageal sphincter and an upper part of the stomach. This myotomy relieves the tightness of the sphincter allowing the normal passage of food from the esophagus into the stomach. At the end of the procedure the doctor uses endoscopic clips to close the incision and the lining of the esophagus, and the endoscope is removed. Initially the esophagus is irritated and cleared, then a submucosal injection is initiated at the cardia in the 2 to 3 o`clock position. The injection is carried approximately on distance of 10 cm from cardiac sphincter. Then the needled knife is used to create a mucosal defect and allow the entry into the submucosal. A dilation balloon is gently inserted into the submucosal and dilate to 12 mm to initiate a submucosal tunnel formation. The endoscope fitted to the cleared cam and then inserted into the submucosal tunnel. ESD technique is then using a triangular type knife in this case to extend a submucosal tunnel through the layers and into the cardia. Here we can see a muscular layer as a white line. Vessels are coagulated using a coagulation grasper. Here the start of the myotomy`s demonstration. Careful dissection is performed in order to reach a plane of dissection between the longitudinal fiber shown here and the circular fibers of the muscular layer of the esophagus. Once this plane is achieved, dissection of the circular layer is performed and carried into the cardia. Here after dissection of muscles of cardia the peritoneal tissue is seen at the base of the dissection. In the endoscope the cut edges of the muscle can be clearly seen. Here is the extent of the myotomy and here the endoscope is withdrawn from the tunnel. The endoscope then is inserted into the cardia to access the effect of the myotomy. Here with a blue discoloration you can see the extent of the tunnel done into the cardia. At the end of the procedure the entry to the submucosal tunnel is sealed with placement of clips.