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DOI: 10.1055/a-2199-6956
The “furrow sign” in confirming proper gastric extent and direction of the myotomy at the end of peroral endoscopic myotomy
Peroral endoscopic myotomy (POEM), first performed by Inoue in 2008, stands as a primary treatment for achalasia [1]. Ensuring the appropriate length of the gastric myotomy is crucial, as a myotomy that is too short can lead to an inadequate response. Conversely, excessive length can result in a higher incidence of moderate reflux esophagitis without enhancing clinical effectiveness [2] [3]. While various landmarks and methods guide the proper extent of the tunnel [4] [5], a straightforward approach to confirm the end of the myotomy is lacking.
Herein, we introduce the concept of the “furrow sign,” characterized by a mucosal depression over a muscular defect in the wall post-myotomy. This sign becomes noticeable during gastric retroflexion under full insufflation, serving to confirm the extent and direction of the myotomy before closing the mucosal incision ([Fig. 1]). To evaluate this sign, full carbon dioxide insufflation is applied in the gastric lumen for 60 seconds after myotomy ([Fig. 2]).
Between May and September 2022, we assessed this sign in seven patients who underwent posterior POEM with comprehensive follow-up. Clinical success was evident in all cases ([Table 1]), and no adverse events linked to full carbon dioxide insufflation during furrow sign evaluation were recorded. On each occasion, the furrow sign was confirmed by at least two endoscopists.
We verified via double-scope transillumination that the depression area seen in the furrow sign aligns with the myotomy area ([Fig. 3]), with its persistence observed even 12 months after POEM ([Video 1]).
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In conclusion, the furrow sign corresponds to the myotomy area and can play a crucial role in confirming or fine tuning the accurate length (and also confirming the direction) of the gastric myotomy at the conclusion of the POEM procedure, prior to closing the mucosal incision. To establish its prevalence, sensitivity, specificity, and interobserver agreement, further studies are imperative.
Endoscopy_UCTN_Code_TTT_1AO_2AN
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Publication History
Article published online:
21 November 2023
© 2023. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/).
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References
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