[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-459868-105":3,"detail-sidebar-cat-0-en-105":80,"doc-detail-459868-en":130},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":73,"head_meta":75,"extra_data":77,"updated_unix":79},105,"en","the-lever-action-drill-technique-a-universal-approach-to-facilitate-efficient-tunneling-in-peroral-endoscopic-myotomy","The Lever-Action Drill Technique - A Universal Approach to Facilitate Efficient Tunneling in Peroral Endoscopic Myotomy","","Peroral endoscopic myotomy relies on extending the submucosal tunnel and performing myotomy beyond the gastroesophageal junction, yet novice operators may struggle to achieve adequate tunnel length when encountering resistance from the lower esophageal sphincter or a curved tunnel. A lever-based concept combining axial stability and friction reduction led to the Lever-Action Drill (LAD) technique. LAD uses lever-like manipulation of the endoscope within the tunnel, promoting smooth advancement through right–left torsional movements. Applicability may be limited in severe fibrosis due to reduced distensibility and higher risk of mucosal injury, requiring careful selection.",{"@graph":14,"@context":72},[15,34,55],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/document/","Document",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/document/healthcare/","Healthcare",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/document/the-lever-action-drill-technique-a-universal-approach-to-facilitate-efficient-tunneling-in-peroral-endoscopic-myotomy/459868/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/the-lever-action-drill-technique-a-universal-approach-to-facilitate-efficient-tunneling-in-peroral-endoscopic-myotomy/459868.png","ImageObject",300,407,{"name":42,"@type":43},"Cart","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-11-08","2026-09-30",true,{"@type":52,"interactionType":53,"userInteractionCount":30},"InteractionCounter",{"@type":54},"ViewAction",{"@type":56,"mainEntity":57},"FAQPage",[58,64,68],{"name":59,"@type":60,"acceptedAnswer":61},"What problem does the Lever-Action Drill (LAD) technique aim to solve in peroral endoscopic myotomy?","Question",{"text":62,"@type":63},"It addresses the difficulty novice operators face when extending the submucosal tunnel sufficiently under strong resistance, such as at the lower esophageal sphincter or within a curved tunnel.","Answer",{"name":65,"@type":60,"acceptedAnswer":66},"How is the LAD technique performed during submucosal dissection?",{"text":67,"@type":63},"After each submucosal dissection, the rigid portion of the endoscope is manipulated like a lever using the mouthpiece as a fulcrum, pushing with slight forward insertion and then releasing to allow controlled right–left rotation.",{"name":69,"@type":60,"acceptedAnswer":70},"When might LAD have limited applicability?",{"text":71,"@type":63},"It may be limited in cases with severe fibrosis, where reduced submucosal distensibility increases the risk of incidental mucosotomies during tunneling.","https://schema.org",{"og:url":32,"og:type":74,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":76,"canonical":32},"index,follow",{"doc_id":78,"site_id":7},459868,1790757129,{"code":4,"msg":81,"data":82},"success",[83,87,91,95,100,105,109,114,119,122,126],{"id":22,"doc_module":4,"doc_module_name":25,"category_name":84,"show_sort_weight":85,"slug":86},"Story & Novel",90,"story-novel",{"id":26,"doc_module":4,"doc_module_name":25,"category_name":88,"show_sort_weight":89,"slug":90},"Literature",80,"literature",{"id":33,"doc_module":4,"doc_module_name":25,"category_name":92,"show_sort_weight":93,"slug":94},"Exam",70,"exam",{"id":96,"doc_module":4,"doc_module_name":25,"category_name":97,"show_sort_weight":98,"slug":99},5,"Comic",60,"comic",{"id":101,"doc_module":4,"doc_module_name":25,"category_name":102,"show_sort_weight":103,"slug":104},6,"Technology",50,"technology",{"id":106,"doc_module":4,"doc_module_name":25,"category_name":29,"show_sort_weight":107,"slug":108},7,40,"healthcare",{"id":110,"doc_module":4,"doc_module_name":25,"category_name":111,"show_sort_weight":112,"slug":113},8,"Research & Report",30,"research-report",{"id":115,"doc_module":4,"doc_module_name":25,"category_name":116,"show_sort_weight":117,"slug":118},9,"Religion & Spirituality",20,"religion-spirituality",{"id":117,"doc_module":4,"doc_module_name":25,"category_name":120,"show_sort_weight":117,"slug":121},"World Cup","world-cup",{"id":123,"doc_module":4,"doc_module_name":25,"category_name":124,"show_sort_weight":123,"slug":125},10,"Lifestyle","lifestyle",{"id":127,"doc_module":4,"doc_module_name":25,"category_name":128,"show_sort_weight":96,"slug":129},19,"General","general",{"code":4,"msg":81,"data":131},{"doc_id":78,"user_id":132,"nickname":42,"user_avatar":133,"doc_module":4,"category_id":106,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":134,"file_id":135,"file_url":136,"file_type":137,"file_size":138,"view_count":30,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":26,"language":139,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":140,"faqs":141,"seo_title":142,"seo_description":12,"update_tm":79,"read_time":96,"preview_page_count":4},18829141979164,"https://eur-avatar.wpscdn.com/davatar_6f874abed73319feea01a86fa6f0fab8","ACG CASE REPORTS JOURNAL   \nVIDEO | ENDOSCOPY  \nThe Lever-Action Drill Technique: A Universal Approach to Facilitate Efficient Tunneling in Peroral Endoscopic Myotomy  \nSatoshi Abiko, PhD, MD 1 ,2 , Yohei Nishikawa, PhD, MD 1 , Yuta Tamaru, MD 1 , Kei Ushikubo, MD 1 , Kohei Shigeta, MD 1 , Kazuki Yamamoto, PhD, MD 1 , Ippei Tanaka, MPH, MD 1 , Mayo Tanabe, PhD, MD 1 , Nikko Theodore Valencia Raymundo, MD 1 , Manabu Onimaru, PhD, MD 1 , Haruhiro Inoue, PhD, MD 1 , and Naoya Sakamoto, PhD, MD2  \n1 Digestive Disease Center, Showa Medical University Koto Toyosu Hospital, Tokyo, Japan  \n2Department of Gastroenterology and Hepatology, Hokkaido University Hospital, Sapporo, Japan  \n\n| CASE REPORT\u003Cbr>In peroral endoscopic myotomy, extension of the submucosal tunnel and myotomy 2 cm beyond the gastroesophageal junction toward the gastric side has been regarded as the standard approach.1,2 However, novice operators often fail to extend the submucosal tunnelsufficiently when strong resistance is encountered duetothe lower esophageal sphincter(LES) or a curved submucosal tunnel. Rotation during endoscopic overtube advancement embodies 2 universal principles—axial stability and friction reduction—which together facilitate smoother progression through the soft and narrow intestinal lumen. By applying these principles, we developed the Lever-Action Drill (LAD) technique. The term drill refers not to excavation but to screw-like rotational advancement.\u003Cbr>The LAD technique was employed within the submucosal tunnel. Following each submucosal dissection, the rigid portion of the endoscope is manipulated like a lever, using the mouthpiece as a fulcrum, by pushing the lever with slight forward insertion (Figure 1). Pushing the rigid portion caused the tip of the endoscope to rotate to the right, and releasing the pushing force of the right hand, while slightly pulling back the endoscope to remove any slack, allowed it to naturally rotate to the left, the right hand to return to the neutral position (Figures 1 and 2) . This series of movements constitutes the LAD technique.\u003Cbr>\u003Cbr>Figure1. Images showing the right hand movements required forthelever-action drill technique. (A)This is the neutral right hand position. (B) The terminal point of the lever push with slight forward insertion is initiated using the mouthpiece as the fulcrum. (C) Releasing the pushing force of the right hand, while slightly pulling back the endoscope to remove any slack, allowed the right hand to return to the neutral position. |\n| --- |\n| ACG Case Rep J 2026;13:e01964 . doi:10 . 14309/crj.0000000000001964. Published online: January 8, 2026 Correspondence: Satoshi Abiko, PhD, MD ([abiko1982@gmail.com](abiko1982@gmail.com)) . |\n\nACG Case Reports [Journal / Volume 13 acgcasereports.com 1](Journal / Volume 13 acgcasereports.com 1)  \nAbiko et al The Lever-Action Drill Technique  \nFigure2. Images showing the right hand movements and endoscopic views in the lever-action drill technique. (A)This is the neutral position of the right hand and the endoscopic view. (B) Pushing the rigid portion causes the tip of the endoscope to rotate to the right.  \nThe lever principle comes into play, and the tip ofthe endoscope rapidly repeats right and left torsional movements with minimal force. These torsional forces reduce friction while maintaining axial stability, enhancing the straight advancement of the endoscope. On the esophageal side, the lever action is often sufficient when gentle and shallow. At the LES and on the gastric side, the lever action is often stronger and deeper, because the tunnel is longer and there is resistance at the LES (Video 1) .  \nLAD technique may facilitate tunneling during peroral endoscopic myotomy. However, its applicability may be limited in cases with severe fibrosis, where reduced submucosal distensibility increases the risk of incidental mucosotomies during the tunneling phase. Careful case selection and cautious handling are therefore required when using ","cbCaimtXeBdkNXbP","https://ap.wps.com/l/cbCaimtXeBdkNXbP","pdf",237350,"English","# Case report\n## LAD technique overview\n## Rationale and procedural principles\n## Limitations and considerations\n## Disclosures and acknowledgments\n## References","[{\"question\":\"What problem does the Lever-Action Drill (LAD) technique aim to solve in peroral endoscopic myotomy?\",\"answer\":\"It addresses the difficulty novice operators face when extending the submucosal tunnel sufficiently under strong resistance, such as at the lower esophageal sphincter or within a curved tunnel.\"},{\"question\":\"How is the LAD technique performed during submucosal dissection?\",\"answer\":\"After each submucosal dissection, the rigid portion of the endoscope is manipulated like a lever using the mouthpiece as a fulcrum, pushing with slight forward insertion and then releasing to allow controlled right–left rotation.\"},{\"question\":\"When might LAD have limited applicability?\",\"answer\":\"It may be limited in cases with severe fibrosis, where reduced submucosal distensibility increases the risk of incidental mucosotomies during tunneling.\"}]","The Lever-Action Drill Technique - A Universal Approach to Facilitate Efficient Tunneling in Peroral Endoscopic Myotomy | PDF"]