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Se presenta el caso de un Redo-POEM tras fracaso de una intervención previa un mes y medio antes de esta reintervención. El paciente es un varón de 42 años con diagnóstico previo de acalasia tipo II (score de Eckardt de 12 puntos) al que se le realizó un POEM posterior. El paciente no mejoró clínicamente y persistían las mismas alteraciones en las pruebas complementarias (tránsito EGD, gastroscopia y manometría HR). En el estudio funcional, el comportamiento clínico y funcional era como una acalasia tipo I. Esto tiene sentido ya que posiblemente lo ocurrido en el primer POEM fue que la miotomía del EII quedó corta. Al seccionar el músculo circular interno (unos 10 cm) del esófago medio y distal junto a la miotomía incompleta del EII, predominaba la disfagia como síntoma cardinal. Se decidió hacer un Redo-POEM posterior lateralizado, a la izquierda del anterior (hacia las 20 horarias, eludiendo la columna vertebral y a menor distancia del EII -a unos 7-8 cm- ya que fundamentalmente interesaba hacer una miotomía completa del EII). De esta forma se simulaba un POEM anterior (muy usado cuando fracasa un POEM posterior). La técnica fue algo mas compleja y larga que en un POEM estándar…
Another case of POEM performed in our hospital. This is a type I achalasia in an 86-year-old man. A standard myotomy (10 cm in length) was performed. An Olympus Triangle tip-J type knife and the ERBE Precise sect mode were used. This configuration allows dissection and coagulation in a more efficient way in ESD and POEM techniques.
Excellent review on the physical principles of precise sect technology and its application in ESD and POEM by Dr. Torsten Beyna and Dr. Roberta Maselli. The precise sect mode regulates itself according to the impedance of the tissue, which in turn is related to the contact surface of the knive with it. Thus, for the precoagulation of medium-sized vessels (0.5-1.5 mm), it is necessary to expose a wide contact surface of the knive on the sides of the vessel (once it has been properly dissected) and press the coagulation pedal during 1-2 seconds. When the vessels are smaller and are not arterial, they can be coagulated with a wide contact surface of the scalpel, without pressing it and pressing the blue pedal for 1-2 seconds. link to website
Precoagulation of medium sized blood vessels (0.5-1 mm) can be achieved with the Precise sect mode through lower impedance. It is achieved by applying larger contact surfaces without pressing the vessel with continuous activation of the coagulation pedal for 1-2 seconds. This may allow ESD and POEM to be performed more safely, without bleeding and therefore more quickly. Link to website
The case of a type II achalasia treated with the POEM technique in a 41-year-old male patient is presented. The entire case is fully exposed without editing.
