Triangle Tip-Jet Knife used as “probe mode” can reduce the risk of mucosal damage during incision and tunneling phase of peroral endoscopic myotomy (POEM) procedures

Peroral endoscopic myotomy (POEM) is a minimally invasive endoscopic technique for the treatment of achalasia and its use has been widely spread in recent years. The Triangle Tip-Jet (TTJ) (Olympus Triangle TipKnife-J, KD645L) has become very popular in this field and currently one of the most used knives for POEM procedures. It has the capability of knife dissection along with submucosal injection and its triangle tip shape is especially useful for pulling tissue during the myotomy phase. However, its length may be too long in situations such as tight esophagogastric junction (EGJ), narrow submucosa due to fibrosis, trimming after mucosal incision and/or less experienced endoscopists3 in which preserving the integrity of the mucosa is vitally important. Distal attachment conical caps like ST Hood (DH28GR,29CR; Fujifilm, Tokyo, Japan) are commonly used for POEM, resting the distal end of the TTJ on the cap, with only the triangular tip protruding. By using straight caps, you can get a wider view and greater maneuverability, however is more difficult to calculate the distance between the triangle tip and the distal attachment end due to its straight shape. The T-shape of the distal TTJ tip was designed for its use in an open position. In this way, while using straight caps and/or less experiences endoscopists during challenging procedures (tight EGJ, submucosal fibrosis) can make them feel unsafe during incision and/or tunneling phase. Herein, we suggest the use of the TTJ knife in “probe mode”4 to reduce the distal knife length from 4.5 mm to 0.3 mm, thus allowing a greater control of the knife tip. In addition, the TTJ probe mode can be safely used with both contact and non-contact currents, which are becoming increasingly popular in recent years. (AU)

Getting it right first time: implementation of laparoscopic pyloromyotomy without a learning curve.

INTRODUCTION: Laparoscopic pyloromyotomy is now an accepted procedure for the treatment of pyloric stenosis. However, it is clear that during the implementation period there are significantly higher incidences of mucosal perforation and incomplete pyloromyotomy. We describe how we introduced a new laparoscopic procedure without the complications associated with the learning curve. MATERIALS AND METHODS: Five consultants tasked one surgeon to pilot and establish laparoscopic pyloromyotomy before mentoring the others until they were performing the procedure independently; all agreed to use exactly the same instruments and operative technique. This involved a 5mm 30-degree infra-umbilical telescope with two 3mm instruments. Data were collected prospectively. RESULTS: Between 1 January 2013 and 31 December 2017, 140 laparoscopic pyloromyotomies were performed (median age 27 days, range 13-133 days, male to female ratio 121:19). Fifty-five per cent of procedures were performed by trainees. Complications were one mucosal perforation and one inadequate pyloromyotomy. There were no injuries to other organs, problems with wound dehiscence or other significant complications. The median time of discharge was one day (range one to six days). CONCLUSION: Our rate of perforation and incomplete pyloromyotomy was 1.4%, which is equivalent to the best published series of either open or laparoscopic pyloromyotomy. We believe that this resulted from the coordinated implementation of the procedure using a single technique to reduce clinical variability, increase mentoring and improve training. This approach appears self-evident but is rarely described in the literature of learning curves. In this age of increased accountability, new technologies should be incorporated into routine practice without an increase in morbidity to patients.

Single-Site Umbilical Laparoscopic Pyloromyotomy Using a Pyloric Electrocoagulation Chisel Combined with a Left-Handed Main Operation for Congenital Hypertrophic Pyloric Stenosis.

Background: Laparoscopic pyloromyotomy has become a gold standard for the treatment of congenital hypertrophic pyloric stenosis (HPS). There have been recent reports on the use of transumbilical single-site laparoscopic surgery for congenital HPS; however, using transumbilical single-site laparoscopic surgery in pediatric cases is still controversial due to the difficulty with manipulation. In this study, some preliminary experience with the application of a novel transumbilical single-site laparoscopic approach in congenital HPS is described. Methods: A retrospective study was conducted involving 25 patients with congenital HPS treated in our hospital from August 2016 to August 2019. A pyloric electrocoagulation chisel combined with a left-handed main operation was completed in all of the patients and the operative times, postoperative length of stay, and operative complications were recorded. Results: The laparoscopic operation was completed in 25 patients with an average operative time of 21.9 ± 5.5 minutes, average postoperative length of stay of 2.5 ± 0.9 days, and no perforations of the pyloric mucosa, recurrent obstruction, surgical incision infections, and incision hernias. All of the patients had at least 3 months of follow-up, good growth and development, and the parents were satisfied with the postoperative scars. Conclusion: A pyloric electrocoagulation chisel combined with a left-handed main operation in the treatment of congenital HPS by a single-site umbilical laparoscopic pyloromyotomy is safe and effective, and can achieve a satisfactory cosmetic effect.

Feasibility of using an led-probe in third-space endoscopy: a clinical study.

BACKGROUND: Third-space endoscopy is a novel, safe, and effective method for treating different gastrointestinal conditions. However, several failed endoscopic procedures are attributed to incomplete myotomy. Lighting devices are used to prevent organic injuries. We aimed to investigate the feasibility of using a hand-made LED-probe (LP) in third-space procedures. METHODS: This prospective study was conducted in a tertiary-care center in Mexico between December 2016 and January 2019. We included peroral endoscopic myotomy (POEM) and gastric peroral endoscopic myotomy(G-POEM) procedures. Pseudoachalasia, peptic ulcer, normal gastric emptying scintigraphy (GES) and prepyloric tumors were excluded. LP was used to guide or confirm procedures. Clinical and procedural characteristics were recorded and analyzed. RESULTS: Seventy third-space procedures were included (42POEM,28G-POEM), with an average patient age of 46.7 ± 14.3 and 43.7 ± 10.1 years, respectively. For the POEM and G-POEM groups, respectively, 18/42(42.9%) and 13/28(46.7%) patients were males; median procedure times were 50 (interquartile range [IQR]: 38-71) and 60(IQR: 48-77) min, median LP placement times were 5(IQR: 4-6) and 6(IQR: 5-7) min, mild adverse events occurred in 4(9.4%) and 4(14.2%) of cases, and clinical success at 6 months occurred in 100 and 85.7% of cases. Integrated relaxation pressure (IRP) improved from 27.3 ± 10.8 to 9.5 ± 4.1 mmHg (p < 0.001); retention percentage at 4 h also improved. LP was successfully placed and adequate myotomy confirmed including 14.2 and 17.8% of POEM and G-POEM difficult patients. CONCLUSIONS: Using an LP is promising and allows guiding during third-space procedures either for submucosal tunnel creation or myotomy confirmation, with excellent safety and efficacy in clinical practice.

Advanced Endoscopic Procedures: An Update for Radiologists.

OBJECTIVE. The purposes of this article are to familiarize radiologists with endoscopic techniques currently in use and to improve identification of clinically relevant imaging findings and procedural complications related to common endoscopic interventions. CONCLUSION. The frequency of performance of therapeutic endoscopic ultrasound-guided procedures has risen precipitously in the last decade. These procedures are replacing surgical and percutaneous approaches to a variety of disease entities. Recent advances include endoscopic bariatric procedures, endoscopic myotomies, and endoscopic ultrasound-guided drainage procedures.

The Application of Pyloric chisel in the Treatment of Hypertrophic Pyloric Stenosis by Single-Site Umbilical Laparoscopic Pyloromyotomy.

OBJECTIVE: The feasibility and perspective of pyloric chisel were discussed through the comparison of pyloric chisel and knife in the treatment of hypertrophic pyloric stenosis (HPS) in single-site umbilical laparoscopic pyloromyotomy (SSULP). METHODS: Fifty-eight cases of HPS treated in our hospital from February 2011 to March 2016 were retrospectively analyzed, in which 30 patients underwent pyloric chisel (Pyloric chisel Group) and 28 patients underwent knife (Knife Group). Operative time, estimated blood loss, and complications between the two groups were analyzed. RESULTS: The operative time was shorter in Pyloric chisel Group than Knife Group (P < .05). The estimated blood loss was lower in Pyloric chisel Group than Knife Group (P < .05). The complication was less in Pyloric chisel Group than Knife Group (P < .05). There were 2 cases of mucosal perforations requiring conversions to open in Knife Group. Five cases of serous tearing occurred in the Knife Group. There was 1 case of serous tearing in the Pyloric chisel Group. All patients were followed up for 3 months, and there was no distinct scar in the umbilical. CONCLUSIONS: Patients were satisfied with no distinct scars in abdominal wall by pyloric chisel or knife to treat HPS in SSULP, but pyloric chisel is more effective and safer.

Peroral Endoscopic Myotomy in Children: First Experience With a New Triangular Knife.

OBJECTIVES: Peroral endoscopic myotomy (POEM) is a novel treatment modality for achalasia cardia. The procedure is technically challenging and time consuming. Recently, a new triangle tip knife (TTJ) has been introduced, which is equipped with water jet facility. In the present study, we analyzed the feasibility, safety, and efficacy of POEM in children with new triangle tip knife. METHODS: We retrospectively evaluated the data of children (18 years or younger) who underwent POEM using TTJ knife at our institution. All POEM procedures were performed under general anesthesia in an endoscopy suite. Technical feasibility, safety, efficacy, and procedure duration were assessed. RESULTS: Ten children (4 boys, 6 girls) with mean age of 14.2 ±â€Š2.74 (9-18) years, underwent POEM with TTJ knife. The subtypes of achalasia cardia were type I (4), type II (5), and type III (1). Two children had prior treatment with pneumatic balloon dilatation. POEM was performed via anterior route in majority of children (70%). Mean operating time was 47.6 ±â€Š19.74 (30-98) minutes with no significant difference between anterior and posterior approaches to POEM (48.57 ±â€Š24.01 vs 45.3 ±â€Š3.51; P < 0.05). Four gas-related adverse events were encountered including capnoperitoneum and retroperitoneal carbon dioxide in 2 children each. Clinical success was noticed in 9 children with significant reduction in Eckardt score at 1 month after POEM (6.7 ±â€Š1.49 vs 0.3 ±â€Š0.48; P = 0.0001). CONCLUSIONS: POEM can be efficiently performed with new triangle knife equipped with water jet technique. Integration of water jet reduces procedure duration and technical difficulty with POEM.