LAUSR

A 42-year-old man with type II achalasia cardia underwent peroral endoscopic myotomy (POEM) by posterior approach. The procedure was started using a gastroscope fitted with a conical hood (DH28GR, Fujifilm, Tokyo, Japan). The gastroesophageal junction (GEJ) was tight when the scope reached the lower end during the creation of the submucosal tunnel. The scope was maneuvered to pass beyond the GEJ. However, the hood became stuck at the tight GEJ and slipped off the gastroscope. During an attempt to remove the hood using a rat-tooth forceps, one portion of the hood chipped off (▶Fig. 1). The hood was tightly stuck in the submucosal tunnel and the mucosa prolapsed inside the tunnel (▶Fig. 2). Forceful removal of the hood could have caused mucosal injury. We decided to proceed with myotomy to decrease the pressure in the submucosal tunnel and create more space. Myotomy was continued until we reached the hood and was carefully extended between the muscle and the hood (▶Fig. 3). The hood immediately became loose and was removed using a rat-tooth forceps (▶Fig. 4, ▶Video1). The submucosal tunnel was extended beyond the GEJ and the myotomy was completed. The patient made an uneventful recovery. This case illustrates that the hood can become dislodged in the submucosal tunnel during POEM and can usually be removed easily [1]. However, if it becomes difficult to remove the hood, as in the present case, myotomy should be carefully performed posteriorly to the hood, which should relieve the pressure in the tunnel and loosen the hood in the submucosal space. One should catch the hood from the mucosal side in order to avoid the prolapse of mucosa around the hood and to facilitate hood removal. Pulling the dislodged hood into the replacement hood will aid safe removal, as for the removal of a foreign body.