You got a lift to get ripped. Injection lift myotomy. A 26 year old male with 12 months of dysphagia and weight loss was found to have type 2 achalasia on manometry. After discussion of risks, benefits, and alternatives, the patient elected to proceed with paraoral endoscopic myotomy, also known as POEM. In a standard POEM, a mixture of saline and methylene blue is injected into the submucosa for better visualization when dissecting the submucosal tunnel. Myotomy is then performed using an endoscopic submucosal dissection ESD knife without further injection. In this presentation, we describe a novel technique for POEM entitled injection lift myotomy. During myotomy, additional solution is injected into the intermuscular and subadventitial spaces in order to permit better visualization of muscle fibers, blood vessels, and extraluminal structures. This facilitates safer and more controlled myotomy. This technique begins in the standard fashion. Following initial saline and methylene blue injection, a mucosal incision was performed to create an entry point to the submucosal space. Using an injection capable ESD knife, the submucosal layer was alternately injected and dissected to create a submucosal tunnel that was extended down to three centimeters into the gastric cardia. At this point, we proceed with the novel injection lift myotomy technique. Again, using the injection capable ESD knife, fluid was directed into the muscularis propria layer, resulting in the expansion of the loose connective tissue in the intermuscular and subadventitial layers. Selective myotomy is then performed from distal to proximal, using pulses of endocut current, alternating with bursts of additional injectate. Injection lift myotomy affords three main advantages. The first is better visualization of muscle fibers for more precise selective circular myotomy. The second advantage is better visualization of extraluminal structures during full-thickness myotomy to both reduce capnoperitoneum and prevent injury to adjacent organs. This is in contrast to what is seen in a standard poem, as visualized on the right, where the myotomy is essentially performed blind. Third, it offers better visualization and therefore avoidance of extraluminal vessels. As seen in this footage of a standard poem where a vessel was inadvertently cut, bleeding can be difficult to control and often extends the length of the procedure. Lastly, in the injection lift myotomy technique, the injectate lifts up the muscle layer to meet the knife, such that less downward pressure is exerted towards the extraluminal tissue, decreasing the chance of injury to extraluminal structures and capnoperitoneum. In conclusion, injection lift myotomy is a novel technique where a mixture of methylene blue and saline is injected into the intermuscular and subadventitial spaces during myotomy. This allows for better visualization of muscle fibers, vessels, and extraluminal structures, allowing for a more precise dissection and decreasing the risk of capnoperitoneum and injury to the extraluminal structures.

injection lift myotomy

paraoral endoscopic myotomy

type 2 achalasia

methylene blue

saline