This ASG video tip is brought to you by an educational grant from Braintree, a part of Cibela Pharmaceuticals, makers of SUTAB. Paranormal endoscopic crurotomy, a useful poem enhancement for advanced akalasia. Disclosures. During our 12-year 800 poem experience, we have found that in a small percentage of patients there is persistent outflow obstruction despite adequate power disruption of the sphincter. Typically, this occurs in patients with long-standing advanced or end-stage akalasia, often after adequate prior myotomy. On barium, outflow obstruction appears to be caused by a sharp angulation of the esophagus at the EGJ, attributable to traction from the right crux. On endoscopy, the ileus orifice is patchy, but there is a sharp angulation of the esophagus at the EGJ as it veers around the right crux, seen as an indentation in the left wall of the esophagus. This is an illustration of the anatomy of the crura. The right crux surrounds the esophagus, as shown here, and has a right and left arm. The right crux puts traction on the esophagus towards the right, thus creating an acute angulation as it enters the stomach. Therefore, it makes sense that doing an endoscopic crurotomy in the right arm of the right crux may facilitate outflow. Poem crurotomy technique. The diaphragmatic crura are dissected excised by surgeons with impunity in cases, for example, of surgical resection of tumors invading the crura. In patients with outflow of traction attributable to the right crux, the offending left arm of the right crux is routinely identifiable and accessible during poem. Extending the poem myotomy into the adjacent crux relieves outflow of traction by creating a more obtuse angle at the EGJ. We started performing this novel poem technique in selected patients in 2011. We present the video of the technique and outcomes in the 19 patients that had this technique, 2.4% of our 12-year series. This is history. 45-year-old man with chronic KB and long-standing achalasia for 8 years. Prior treatment, Heller-Plasdor in 2012 with partial initial response followed by a gradual recurrence of dysphagia over the past two years and currently severe dysphagia with a NECAR score of 8. Barium showed esophageal dilation, sharp angulation at the EGJ and slow emptying. EGD showed a patchy loose alias but sharp turn of the esophagus around the imprint of the right crux. EGD showed modest instensibility of 2.5 and minimal diameter for 13.4 mm and we proceeded with proem with crurotomy in June of 2020. This shows this indentation from the right crux. The alias is patchy loose from the prior Heller but there is a sharp angulation of the esophagus because of the right crux shown there. We start as usual with proem. We inject submucosal solution and enter the submucosal plane as shown here. We use a multifunctional knife that can inject and coagulate at the same time. Here we coagulate the vessel and slowly we extend the tunnel to the cardia and then we start with the myotomy as usual. We cut the circular and other longitudinal layer exposing the adventitia of the esophagus and extend the myotomy all the way to about 2 cm into the cardia. This was a short myotomy of 4 cm and a short tunnel of approximately 7 cm. After completion of the full thickness myotomy which is our preferred technique for proem We can see the crux here. It has a characteristic orange-red salmon-like color and then we just isolate fiber by fiber and cut it using a dry cut current or a coagulating current. That causes spastic contractions of skeletal muscle. So small bursts of energy are preferable with somewhat coagulating currents. Here we continue the dissection of the left arm of the right crux at 7 o'clock position which is the preferred orientation to access the crux. Now we check and see what the effect was. We can still see the indentation and the orifice is suboptimal therefore we proceed with further crurotomy. Overall it is a partial crurotomy but the degree of muscle dissected is titrated according to the effect on the orifice at the EGJ. So here we take additional muscle bundles. Again the orientation is at 7 o'clock for this type of poem and this identifies this arm of the right crux very well. Now we check again the orifice which is shown here and we find it adequate so we proceed with end of lip measurements which are also very adequate. Minimal diameter is now 22 mm and distanceability 8.9 and you can see the before-after pictures at the start and the end of the poem, very wide open high orifice now and we proceed with closure of the tunnel opening using as usual for us the overstitch, there was some bleeding from an edge vessel which will be ligated as soon as we cinch the suture. Here we release the needle and we cinch as per usual and it is a very secure closure of the tunnel. You can see on the barium the before, sharp angulation caused by the crux with slow emptying. After much more obtuse angle with rapid emptying and even reflux from the stomach. Procedural characteristics and follow-up, short myotomy and short tunnel about 7.4 cm at 7 o'clock, decent procedure times, closure with overstitch 6 minutes, end of lip very good results, dimin 13 mm to 22, distanceability 2.5 goes to 8.9. On 17 month follow-up, no dysphagia or other symptoms, ECARD score of 0, rapid emptying on barium, patient takes PPIs intermittently with heartburn episodes approximately once per week. This table shows our 19 crurotomy cases over a period of 10 years, I'll give you the summary on the last row here, total and means, 10 men, 9 women, median age 59, duration of disease 135 months, 68% had prior treatment, half of them prior myotomy, 53% advanced disease as expected for this type of patients with 37% sigmoid, nevertheless excellent results, the pre-score of 7 goes to 0 at median follow-up of 2.4 years, 100% clinical success, 50% positive PH studies, median length of stay of 3 days, no severe adverse events, the only adverse event was mild self-limited chest pain and shortness of breath that was seen in 21% of patients. In conclusion, crurotomy may represent an important poem adjunct in patients with long-standing disease and adequate prior sphincter disruption that have residual or recurrent outflow obstruction attributable to angulation caused by the cruise. Our preliminary results on 19 patients demonstrate excellent feasibility and remarkable efficacy and safety.

endoscopic crurotomy

advanced achalasia

outflow obstruction

myotomy

multifunctional knife