Name: use of the scissor-type knife during the peroral endoscopy myotomy procedure for the treatment of achalasia
Uploaded: 2023-03-03T12:00:00
Description: Watch this Scientific Journal Video about Use of the Scissor-Type Knife During the Peroral Endoscopy Myotomy Procedure for the Treatment of Achalasia at JoVE.com

This research was not supported by any grants.

The protocol was conducted in accordance with the Declaration of Helsinki and the protocol was approved by the Institutional Review Board at the First Affiliated Hospital of Sun Yat-sen University.
1. Patient selection
<ol>
	<li>Diagnose achalasia by clinical manifestations and diagnostic testing (barium esophagram, high-resolution manometry (HRM), and upper endoscopy)10: the presence of symptoms such as dysphagia, regurgitation, chest pain, and weigh...

<ol>
	<li>Khashab, M. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=ASGE+guideline+on+the+management+of+achalasia.">ASGE guideline on the management of achalasia.</a> Gastrointestinal Endoscopy. 91 (2), 213-227 (2020).</li><li>Liu, Z., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comprehensive+evaluation+of+the+learning+curve+for+peroral+endoscopic+myotomy.">Comprehensive evaluation of the learning curve for peroral endoscopic myotomy.</a> Clinical Gastroenterology and Hepatology. 16 (9), 1420-1426 (2018).</li><li>Patel, K. S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+light+at+the+end+of+the+tunnel:+a+single-operator+learning+curve+analysis+for+per+oral+endoscopic+myotomy.">The light at the end of the tunnel: a single-operator learning curve analysis for per oral endoscopic myotomy.</a> Gastrointestinal Endoscopy. 81 (5), 1181-1187 (2015).</li><li>Cai, M. Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Peroral+endoscopic+myotomy+for+idiopathic+achalasia:+randomized+comparison+of+water-jet+assisted+versus+conventional+dissection+technique.">Peroral endoscopic myotomy for idiopathic achalasia: randomized comparison of water-jet assisted versus conventional dissection technique.</a> Surgical Endoscopy. 28 (4), 1158-1165 (2014).</li><li>Tanaka, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Peroral+endoscopic+myotomy+using+FlushKnife+BT:+a+single-center+series.">Peroral endoscopic myotomy using FlushKnife BT: a single-center series.</a> Endoscopy International Open. 5 (7), 663-669 (2017).</li><li>Oka, S., Tanaka, S., Takata, S., Kanao, H., Chayama, K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Usefulness+and+safety+of+SB+knife+Jr+in+endoscopic+submucosal+dissection+for+colorectal+tumors.">Usefulness and safety of SB knife Jr in endoscopic submucosal dissection for colorectal tumors.</a> Digestive Endoscopy. 24, 90-95 (2012).</li><li>Yoshida, N., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Efficacy+of+scissor-type+knives+for+endoscopic+mucosal+dissection+of+superficial+gastrointestinal+neoplasms.">Efficacy of scissor-type knives for endoscopic mucosal dissection of superficial gastrointestinal neoplasms.</a> Digestive Endoscopy. 32 (1), 4-15 (2020).</li><li>Kuwai, T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endoscopic+submucosal+dissection+of+early+colorectal+neoplasms+with+a+monopolar+scissor-type+knife:+short-+to+long-term+outcomes.">Endoscopic submucosal dissection of early colorectal neoplasms with a monopolar scissor-type knife: short- to long-term outcomes.</a> Endoscopy. 49 (9), 913-918 (2017).</li><li>Yamashina, T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Scissor-type+knife+significantly+improves+self-completion+rate+of+colorectal+endoscopic+submucosal+dissection:+Single-center+prospective+randomized+trial.">Scissor-type knife significantly improves self-completion rate of colorectal endoscopic submucosal dissection: Single-center prospective randomized trial.</a> Digestive Endoscopy. 29 (3), 322-329 (2017).</li><li>Vaezi, M. F., Pandolfino, J. E., Yadlapati, R. H., Greer, K. B., Kavitt, R. T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=ACG+clinical+guidelines:+diagnosis+and+management+of+achalasia.">ACG clinical guidelines: diagnosis and management of achalasia.</a> The American Journal of Gastroenterology. 115 (9), 1393-1411 (2020).</li><li>Eckardt, A. J., Eckardt, V. F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Treatment+and+surveillance+strategies+in+achalasia:+an+update.">Treatment and surveillance strategies in achalasia: an update.</a> Nature Reviews. Gastroenterology and Hepatology. 8 (6), 311-319 (2011).</li><li>Jones, R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Development+of+the+GerdQ,+a+tool+for+the+diagnosis+and+management+of+gastro-oesophageal+reflux+disease+in+primary+care.">Development of the GerdQ, a tool for the diagnosis and management of gastro-oesophageal reflux disease in primary care.</a> Alimentary Pharmacology &amp; Therapeutics. 30 (10), 1030-1038 (2009).</li><li>Bittinger, M., Messmann, H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Use+of+the+stag-beetle+knife+for+peroral+endoscopic+myotomy+for+achalasia:+a+novel+method+for+myotomy.">Use of the stag-beetle knife for peroral endoscopic myotomy for achalasia: a novel method for myotomy.</a> Gastrointestinal Endoscopy. 82 (2), 401-402 (2015).</li><li>Hathorn, K. E., Chan, W. W., Aihara, H., Thompson, C. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Determining+the+safety+and+effectiveness+of+electrocautery+enhanced+scissors+for+peroral+endoscopic+myotomy+(with+Video).">Determining the safety and effectiveness of electrocautery enhanced scissors for peroral endoscopic myotomy (with Video).</a> Clinical Endoscopy. 53 (4), 443-451 (2020).</li><li>Mohan, B. P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Anterior+versus+posterior+approach+in+peroral+endoscopic+myotomy+(POEM):+a+systematic+review+and+meta-analysis.">Anterior versus posterior approach in peroral endoscopic myotomy (POEM): a systematic review and meta-analysis.</a> Endoscopy. 52 (4), 251-258 (2020).</li></ol>

As an evolving endoscopic surgical treatment for achalasia, POEM requires both advanced endoscopic skills and knowledge of surgical anatomy. A recent study demonstrated that POEM comes with a considerable learning curve that increases the risk of technical failure, adverse events, and clinical failure2. Endoscopists, especially trainees who have not completed their learning phase, commonly face difficulty in accurate manipulations of the endoscopic knife while working near the EGJ with limited wor...

Peroral endoscopic myotomy (POEM) has gained worldwide acceptance as one of the first-line treatment modalities along with pneumatic dilation and Heller myotomy for patients with achalasia1. To date, most POEM procedures have been confined to a few high-volume, specialized centers. Previous studies have shown that even operators skilled in laparoscopy or endoscopy have a steep learning curve when they are beginning to perform POEM and a higher volume of cases is required to manage challenging situations and prevent adverse events2,3. During POEM procedures, endoscopic needle-knives are most commonly used for both submucosal tunneling and myotomy, combined with hemostatic forceps for managing large vessels and active bleeding. However, because of the impaired esophagogastric junction (EGJ) relaxation in patients with achalasia, the limited space at the level of the EGJ increases the technical difficulty of tissue plane dissection and selective myotomy using the needle-type knife. Besides, operators who are still in the learning phase could be less proficient in exchanging the hemostatic forceps for bleeding control, which may lead to poor visibility and even further inadvertent mucosal injury.
Various endoscopic knives have been used in the POEM procedures for better manipulations and safety profiles4,5. The junior scissor-type knife (Stag-beetle Knife Jr.) with two monopolar blades that are both insulated externally was originally developed for accurate manipulations in colorectal endoscopic submucosal dissection (ESD)6. The standard techniques used with the scissor-type knife involve grasping the target tissue, and then dissection or coagulation. Theoretically, tissue injury caused by unintentional movement could be avoided with a scissor-type knife as compared with a needle-type knife7. Several studies have demonstrated the feasibility and safety of using the scissor-type knife for all ESD procedures, including mucosal incision, submucosal dissection, and hemostasis7,8. Meanwhile, a recent randomized controlled trial showed that the scissor-type knife significantly improved the trainees' self-completion rates for colorectal ESD9. It can be speculated that these advantages of the scissor-type knife can promote a safer POEM procedure, especially during the trainee's early cases. To minimize the technical difficulty and improve the safety of POEM, we described a protocol for using a scissor-type knife for the main steps of the POEM procedure, including mucosal incision, submucosal tunneling, myotomy, and hemostasis. Three patients with achalasia who received POEM using the scissor-type knife were presented to evaluate the feasibility and clinical outcomes of this protocol.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Electrogenerator</td>
			<td>ERBE Elektromedizin</td>
			<td>VIO 200S</td>
			<td></td>
		</tr>
		<tr>
			<td>Endoclip</td>
			<td>Micro-Tech (Nanjing)</td>
			<td>ROCC-D-26-195-C</td>
			<td></td>
		</tr>
		<tr>
			<td>Endoscope</td>
			<td>Olympus</td>
			<td>GIF-H260</td>
			<td></td>
		</tr>
		<tr>
			<td>Injection Needle</td>
			<td>Olympus</td>
			<td>NM-400L-0423</td>
			<td></td>
		</tr>
		<tr>
			<td>Stag Beetle Knife Jr</td>
			<td>Sumitomo Bakelite</td>
			<td>MD-47703W</td>
			<td></td>
		</tr>
		<tr>
			<td>Transparent Distal Cap</td>
			<td>Olympus</td>
			<td>D-201-11804</td>
			<td></td>
		</tr>
	</tbody>
</table>

use of the scissor-type knife during the peroral endoscopy myotomy procedure for the treatment of achalasia

Peroral endoscopic myotomy (POEM) is one of the first-line treatment modalities along with pneumatic dilation and Heller myotomy for patients with achalasia. Endoscopists, especially trainees during the learning phase, commonly face difficulty in tissue plane dissection and selective myotomy while working near the esophagogastric junction, with increased risks of inadvertent injury, unexpected bleeding, and inadequate myotomy. To minimize the technical difficulty and improve the safety of POEM, we describe a protocol for using a scissor-type knife for the main steps of POEM, including mucosal incision, submucosal tunneling, myotomy, and hemostasis. The standard techniques used with the scissor-type knife involve grasping the target tissue, and then dissection or coagulation. The confirmation of the cutting line after grasping improves the accuracy and reliability of dissection, which is particularly useful for the selective myotomy of the internal circular muscle. Meanwhile, the scissor-type knife provides enhanced hemostatic capability and enables hemostasis and pre-coagulation without the device exchange for hemostatic forceps. Evaluation of the clinical outcomes in three patients who successfully received POEM using the scissor-type knife revealed no perioperative adverse events. At the 3-month follow-up, all patients achieved clinical success with postoperative Eckardt scores ranging from 0 to 1. In conclusion, the use of a scissor-type knife could minimize the technical difficulty and improve the safety of the POEM procedures, which may be suitable for trainees during the learning phase.

Compared with the needle-type knife, the scissor-type knife enables coagulation and dissection after grasping the target tissue. Meanwhile, the scissor-type knife is equipped with an enhanced hemostatic capability similar to hemostatic forceps and insulated coating external of the two blades (Table 1). Three patients with achalasia received POEM using the scissor-type knife in our institution. Sigmoid esophagus was present in one patient. One patient had previously undergone pneumatic dilation. Technical...

Watch this Scientific Journal Video about Use of the Scissor-Type Knife During the Peroral Endoscopy Myotomy Procedure for the Treatment of Achalasia at JoVE.com

Use of the Scissor-Type Knife During the Peroral Endoscopy Myotomy Procedure for the Treatment of Achalasia

To minimize the technical difficulty and improve the safety of peroral endoscopic myotomy (POEM), we describe a protocol for using a scissor-type knife for the main steps of POEM, including mucosal incision, submucosal tunneling, myotomy, and hemostasis.

Peroral endoscopic myotomy (POEM) is one of the first-line treatment modalities along with pneumatic dilation and Heller myotomy for patients with ...

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