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H. Manner, Wiesbaden

Sequenzen:

Sequence 1 — case report / presentation of the patient

This is the case of a 62-year-old female patient who had developed a gastric emptying disturbance as a result of injury to the vagus nerve during fundoplication that was carried out twice. She reported a feeling of postprandial fullness and sometimes cramp-like upper abdominal symptoms. As pylorospasm had been identified endoscopically and pathological gastric emptying had been seen on scintigraphy, she had already undergone several balloon dilation procedures and Botox injections in the area of the pylorus. However, these procedures had only led to symptomatic improvement for 2–3 weeks. As the patient had declined repeat surgery, we decided in agreement with her to carry out a peroral endoscopic myotomy of the pylorus muscle — known as gastric POEM.

Sequence 2 — initial findings

The pylorus is stenotic. After a 3-day fast, the stomach is empty of any solid food.

Sequence 3 — injection into the submucosa

An injection with Glycerosteril (glycerol) and indigo carmine is carried out in the area of the later mucosal incision, 5 cm away from the pylorus.

Sequence 4 — incision into the gastric mucosa in front of the pylorus

The incision is now made for the entrance into the later submucosal tunnel. An ESD knife — the Flush Knife — is used, allowing alternate cutting and injection.

Sequence 5 — tunneling in the submucosa

With additional injection, coagulation, and gentle advancement with the cap, an entrance into the tunnel can be created. The blue-stained submucosa, with a spider’s-web appearance, is very clearly seen here. Using coagulation current, it is gradually transected. Attention is given to ensure that one always stays as far from the mucosa as possible, to avoid perforation into the genuine gastric lumen. Fluid is also repeatedly injected.

Sequence 6 — demonstration of the pyloric muscle ring

The ring of pyloric muscle now becomes visible as a whitish, rounded structure. A mark is made for the later myotomy. Caution: one must not cut through the mucosa into the duodenal bulb.

Sequence 7 — myotomy of the pyloric muscle

The myotomy now starts, using coagulation current while the endoscope is slowly withdrawn.

Sequence 8 — complete transection of the pyloric muscle

The pyloric muscle opens up. The myotomy is carefully continued until practically all of the muscle fibers in the area of the pylorus have been transected.

Sequence 10 — extension of the myotomy

Extension of the myotomy 2 cm proximally now follows.

Sequence 11 — Closure of the submucosal tunnel

The entrance to the tunnel is closed with clips.

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