Recent advances in third space or intramural endoscopy

Figure 1 Peroral endoscopic myotomy. A: Submucosal injection in the mid esophagus to create a submucosal bleb, followed by a mucosal incision to enter the submucosal space; B: Create a submucosal tunnel along the esophageal length; C and D: Esophagogastric myotomy; E: Closure of submucosal entry point with endoscopic clips. Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography^© 2015-2020. All Rights Reserved.

Figure 2 Per-oral Pyloromyotomy. A: Submucosal injection with a coloring agent proximal to the pylorus to create a submucosal bleb; B: Mucosotomy; C: Dissection of the submucosa until the pylorus is identified; D: Pyloromyotomy performed in a distal to proximal fashion; E: Closure of the mucosotomy by endoscopic clips. Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography^© 2015-2020. All Rights Reserved.

Figure 3 Submucosal tunneling endoscopic septum division. A and B: Mucosal incision proximal to the septum followed by creation of a submucosal tunnel; C: Cricopharyngeal muscle fibers dissected to the bottom of the diverticulum; D and E: Closure of the entry site with endoscopic clips. Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography^© 2015-2020. All Rights Reserved.

Figure 4 Endoscopic submucosal dissection. A: Lesion marked with cautery; B: Submucosal injection to create a bleb; C: Circumferential mucosal incision; D: Followed by submucosal dissection until the lesion is removed. Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography^© 2015-2020. All Rights Reserved.