Feasibility of peroral endoscopic myotomy with a disposable endoscope platform

Video Video 1 Demonstration of a successful peroral endoscopic myotomy using a novel disposable scope platform.

scope into the stomach (Fig. 1A).A mixture of methylene blue and saline was injected to create a submucosal cushion 12 cm above the gastroesophageal junction (GEJ) at 2 o'clock using an injection needle (NeedleMaster; Olympus America Inc, Center Valley, Pa, USA) (Fig. 1B).A 2-cm longitudinal incision was then made into the submucosa using an electrocautery dissection knife (Hybrid T knife; Erbe USA, Inc, Marietta, Ga, USA) with an ERBE generator (Erbe USA, Inc) using ENDO CUT Q mode (effect 2, cutting duration 3, cutting interval 3) (Fig. 1C).
The endoscope with a cap was advanced into the tunnel, and the submucosal tunnel was created using the electrocautery knife and a series of submucosal injections using "Precise Sect" mode (Precise Sect, 5.7) (Fig. 1D).The tunnel was stopped in the lesser curvature of the stomach, 2 cm below the GEJ.Subsequently, a full-thickness myotomy was performed (Fig. 1E).The initial incision was then closed with 6 hemostatic clips (Dura Clips, 11mm; ConMed USA, Utica, NY, USA) (Fig. 1F).At the conclusion of the procedure, we were able to advance the endoscope through the GEJ without any resistance (Video 1, available at www.videogie.org).An esophagram on the following day did not reveal any leak, and he was discharged without any adverse events.His Eckert score improved to 0 from 5 at his 4-week follow-up.A follow-up endoscopy at 6 months showed a widely patent GEJ.

CONCLUSION
In comparison to reusable endoscopes, a disposable scope has a similar length (1030 mm), provides the same degree of retroflexion (up 210 , down 90 , right 100 , left 100 ), and is able to fit with the clear attachment caps (Fig. 2, Table 1).Despite the lack of high-definition electrochromoendoscopy optics, the disposable endoscope provided adequate-quality endoscopic illumination during all stages of POEM, including submucosal injection, incision/tunnel entry, dissection, myotomy, closure, and retroflexion view within the stomach (Fig. 3).Despite the lower pixel density of the disposable endoscope, the color contrast between the submucosa and the muscle layer was satisfactory to enable safe and efficient tunneling.During myotomy, it clearly differentiated the circular and longitudinal muscles with favorable image quality (Fig. 3).The 2.8-mm inner working channel allows for easy passage of endoscopic equipment such as an electrocautery knife and hemostatic clips with adequate and satisfactory rotatability.Despite its flexibility, the device has sufficient stiffness for quick tunnel entry, similar to the reusable endoscope.Considering the similarities in design of the disposable endoscope with the reusable endoscope, we anticipate no learning curve associated with this device.Disposable endoscopes are not only suitable for use in immunocompromised patients and those with multidrugresistant organisms, but also because of their flexible design and lighter weight, which is advantageous ergonomically for longer, complex procedures such as POEM to prevent long-term muscle injury.The future design of disposable endoscopic platforms should be tailored to advance specific needs of each complex therapeutic procedure and to address current limitations of this platform, such as lack of image enhancement and near-focus capabilities.

DISCLOSURE
Dr Othman is a consultant for Olympus, Boston Scientific Corporation, AbbVie, ConMed, Lumendi, AMBU, Creo Medical, Neptune Medical, and Apollo; he has also received research grants from Lucid Diagnostics, AbbVie, AMBU, Boston Scientific, Olympus, and ConMed.Dr Keihanian is a consultant for Lumendi, ConMed, and Neptune Medical.Dr Jawaid is a consultant for Creo Medical, Lumendi, and ConMed.
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Figure 2 .
Figure 2. Side-by-side ex vivo comparison of disposable scope and reusable scope (A, length, B. distal tip width/design, C and D, retroflexion capability, E, scope handle, and F and G, compatibility with distal clear attachment cap).

Figure 3 .
Figure 3. Side-by-side demonstration of the image quality by a disposable scope and a reusable scope (A, forward scope viewing, B, tunneling, and C, myotomy).

TABLE 1 .
Side-by-side comparison of reusable and disposable scopes *Illumination intensity is proprietary.