Post written by Hugo Uchima, MD, from the Endoscopy Unit, Gastroenterology Department, Hospital Universitari Germans Trias i Pujol, Badalona, and the Endoscopic Unit, Teknon Medical Center, Barcelona, Spain.
In this video, we describe the technical and anatomic endoscopic references to preserve the innermost gastric oblique fibers (sling fibers) during posterior POEM, based on the location of the 2 penetrating vessels (TPVs) described by Tanaka in 2018 (two penetrating vessels as a novel indicator of the appropriate distal end of peroral endoscopic myotomy).
The preservation of the sling fibers may help to prevent post-POEM GERD since they help to maintain the acuity of the angle of His. The first penetrating vessel was usually found immediately after or 1 cm distal to the narrow gastroesophageal junction (GEJ), at the 6 o’clock position, and the second vessel usually was 1.5 to 2 cm distal (to the first vessel), at the 5 or 4 o’clock position. Sling fibers were seen as internal oblique fibers running at the left side of the TPVs.
The video is important because the recognitition of TPVs as a landmark to end the submucosal tunnel and guide the myotomy direction to spare the sling fibers during posterior POEM has the potential of reducing the incidence of post-POEM GERD.
We hope this video might help to understand the location of the 2 penetrating vessels and recognize the sling fibers during posterior POEM. In cases where TPVs or sling fibers are not identified, the tunneling and subsequent myotomy at the gastric level at the 3 to 4 o’clock position (toward the lesser curvature) might be equivalent.
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