Per-oral endoscopic myotomy: Major advance in achalasia treatment and in endoscopic surgery

Figure 1 Per-oral endoscopic myotomy technique. A: Prior to per-oral endoscopic myotomy (POEM), there is evidence of a tightly puckered lower esophageal sphincter (LES); B: Submucosal injection is performed with saline stained with indigo carmine; C: Mucosotomy is performed along the right anterior wall of the esophagus; D: Submucosal dissection is performed with hybrid knife; E: Submucosal tunnel is extended into the gastric cardia; F: Myotomy is intiated 2 cm below site of mucosotomy; G: Final full thickness myotomy is seen as endoscope is withdrawn from the submucosal tunnel; H: Mucosotomy is closed with an endoscopic suturing device; I: After POEM, the LES appears patulous.