Editing Intramural endoscopic surgery


AKA 'third-space endoscopy'

== Procedures ==

# POEM
# Peroral pyloromyotomy for gastroparesis (gastric-POEM)
# Submucosal tunnelling endoscopic resection of subepithelial tumours (STER)
# Flexible endoscopic diverticulotomy for Zenker (FED)
# Peroral endoscopic tunneling for restoration of the oesophagus (POETRE)

== Basic principles ==

* Use of the submucosal plane, which is the plane between mucosa and muscularis propria, comprised of loose areolar tissue
* GA is highly preferable
* Abx should include antifungals
* Diagnostic endoscopy is performed

== Procedure ==

* Initial submucosal bleb injection with mucosal flap incision - make sure it's of appropriate distance from the planned myotomy site - you want a bit of distance to allow this submucosal tunnel to act as a flap/valve if you perforate distally at the myotomy site
** Can use a mixture incorporating methylene blue, adrenaline and saline to raise the bled (the dye helps to identify the submucosa)
** If you don't see a weal developing, you're probably too deep, and need to draw back
* Creation of submucosal tunnel - use short bursts of electrocautery - may need repeated injections of submucosal fluid
* Myotomy/lesion excision
* Mucosal flap closure - easiest with haemostatic clips

== Post-procedure ==

* Baseline erect CXR
* Get another CXR if patient deteriorates clinically
* Upper GI contrast study on day 1 - looking for leak or obstruction
** If no major issues, start on liquid diet
* Most patients stay 24 hours or so
* Liquid diet 1-2 weeks
* PPI +/- sucralfate to prevent ulceration at myotomy

[[Category:Endoscopy]]