per-oral endoscopic myotomy using an endoscopic dissector, another novel device in our toolbox. The authors include Shruti Mouni, Olaya Brewer-Gutierrez, Michael Bejjani, Bashir Ghandour, and Moeen Khashab. There was no funding for the making of this video and the following are our disclosures. POEM has emerged as a safe and effective technique for the management of echolesia and other non-echolesia motility disorders. While the procedural technique has remained homogeneous, several types of electrosurgical knives continue to evolve with the aim to improve technical challenges associated with POEM. As shown in the table, among the electrosurgical knives, the triangular tip knife and the hybrid knife are commonly used, while the newer devices which were recently reported include the stag beetle knife, the flush knife with ball tip, and electrocautery-enhanced scissors. The coagulation forceps is commonly used for hemostasis. Along the same armamentarium of novel devices is the endoscopic dissector, which is known for its use in ESD, serving the function of blunt dissection and hemostasis. There is no data for its use in POEM and thus we present the first case of an endoscopic dissector being used for POEM and highlighting its clinical and technical advantages. An 89-year-old male presented with solid food dysphagia and 15-pound weight loss over two years. His upper endoscopy and high-resolution manometry confirmed type 2 echolesia. His ECART score was 6 and he opted for a POEM procedure. We performed a standard anterior approach POEM where a submucosal injection was followed by a longitudinal mucosal incision approximately 10 centimeters above the GE junction. The endoscope now entered the submucosal space. For the next steps of our procedure, which was submucosal tunneling and myotomy, we used the novel endoscopic dissector device. This is a monopolar electrosurgical instrument with a rotatable and flexible shaft, a curved grasper tip design with a tip opening diameter of 6 millimeters. It can go through a working channel diameter of 2.8 millimeters. After entering the submucosal space, tunneling is done with the endoscopic dissector. Its forceps like jaws not only grasp the fibers but also allow controlled blunt dissection as shown. This is done using spray coagulation settings at 40 watts, effect 2. Bleeding is a known occurrence intra-procedurally which can easily be managed with the same electrocautery enhanced dissector by grasping the vessels, applying coagulation current and achieving successful hemostasis. Smooth tunneling is continued using the closed tips of the dissector while avoiding injury to the mucosal layer. The curved grasper tip design and 90 degree rotatability facilitates easy passage through narrow areas in the submucosal tunnel such as during passage through the lower esophageal sphincter. Accurate blunt dissection is done using the controlled opening and closing of the tip, avoiding contact with the muscle layer as well as the mucosal layer. This type of dissection further allows optimal targeting of the submucosal fibers. As depicted in the video, tunneling is done not only with the closed tips of the dissector but also by grasping the target tissue allowing for a controlled resection. The submucosal fibers were dissected and the tunnel is extended 2 to 3 centimeters into the proximal stomach at which juncture submucosal tunneling is complete. Here we see the entire extent of the submucosal tunnel including the mucosal entry site from the lumen. Next we perform the esophageal myotomy starting 2 centimeters distal to the mucosal entry site. Myotomies perform using the same dissector by carefully cutting the inner circular muscle fibers until the external longitudinal muscle bundles are exposed. The sharp teeth tip and grasping forceps like design can precisely control the thickness of the muscle incision which can effectively maintain the integrity of the esophageal mucosa. Full thickness myotomy was performed at 40 watts effect 2. Division of the lower esophageal sphincter muscle is continued in a step-by-step manner till the endoscope is passed 3 centimeters into the gastric cardia. The myotomy was then complete and the mucosal entry site was closed using endoclips. Our patient did well post-POEM procedure and the esophagogram done the next day was negative for a leak. At one month follow-up he reported significant improvement in symptoms with an ECARD score of 1. His endoflip measurements also showed improvement in the distensibility index from 0.8 pre-myotomy to 4.6 post-myotomy. At one year follow-up he reported no symptoms of dysphagia or reflux. Our case highlights the myriad of technical and clinical advantages of the endoscopic dissector. The curved grasper tip design with sharp teeth, rotatability and flexible shaft all allow performing essential steps of the POEM procedure including mucosotomy, submucosal tunneling and myotomy while also controlling bleeding. From a clinical perspective this dissector uses the concept of novel blunt dissection without the use of electrocautery. It also improves ergonomic performance, decreases the need to change instruments during the procedure, allows easy maneuverability in narrow areas such as those in the LES and reduces the risk of esophageal perforation, overall making it less cumbersome for less experienced operators. All these features assist with potentially improving procedure time and cost. The endoscopic dissector is thus an excellent electrosurgical instrument enabling all the key steps to allow successful completion of POEM. It is worth noting that although in our case a triangular tip knife was used for mucosotomy, the endoscopic dissector may be used to perform this step. In conclusion, the endoscopic dissector is a readily available device in our toolbox. It appears to be feasible and safe in POEM and thus should be considered. Comparative trials using an endoscopic dissector with other devices for POEM is warranted to establish the role of this novel device.

endoscopic dissector

per-oral endoscopic myotomy

electrosurgical knives

stag beetle knife

electrocautery-enhanced scissors