"Posterior-like" anterior peroral endoscopic myotomy: a novel concept.

Peroral endoscopic myotomy (POEM) has been established as an emerging technique for the management of Achalasia.Currently, two different approaches have been described, depending on the operator’s preference: with the patient in the supine position, anterior POEM is performed at the 2 o’clock position, while posterior POEM is performed at the 6 o’clock position. Recent data show them to have similar efficacy [1,2], suggesting less acid exposure after anterior POEM but a higher rate of mucosotomies due to the tangential approach [1]. In posterior POEM the dissection plane is more convenient; however, the pooling of liquids/blood in the 6 o’clock position can be disturbing. Here we describe how to perform anterior POEM while benefiting from the advantages of posterior POEM.

Once the mucosal entry has been created, the endoscopist’s body is turned towards the patient’s feet, where a second monitor is placed, and the shaft of the endoscope is rotated anticlockwise (Fig. 1). In this way the axis of the tunnel is positioned at the 5-7 o’clock position (Fig. 2, Video 1). Further dissection and myotomy are continued using the monitor placed by the patient’s feet. So far, we have experience from 3 cases of “posterior-like” anterior POEM with a technical success rate of 100%.

Figure 1

(A) Standard setup for anterior peroral endoscopic myotomy (POEM). (B) Setup for “posterior-like” anterior POEM. The endoscopist performs the procedure through the monitor placed by the patient’s feet

Figure 2

Endoscopic view of “posterior-like” anterior peroral endoscopic myotomy at the 5-7 o’clock position. (A) Mucosal entry. (B) Tunneling and exposure of the muscle layer. (C) Full-thickness myotomy. (D) Closure of the mucosal entry

Video 1

Video demonstration of posterior-like anterior peroral endoscopic myotomy ((https://www.youtube.com/watch?v=490ODFulPx8&feature=youtu.be))