LAUSR

As a primary treatment for patients with achalasia [1], peroral endoscopic myotomy (POEM) is a technically demanding procedure [2]. To perform a high-quality POEM and to prevent complications such as leakages, infections, major bleeding, and gas-related events, the establishment of a submucosal tunnel and the integrity of the mucosal flap are crucial [3, 4]. We present a blunt dissection technique to achieve rapid and safe submucosal tunneling in the aim to build a technically simplified POEM, which we call blunt POEM (▶Video 1). A 58-year-old woman suffered from solid food dysphagia and regurgitation. The endoscopy presented two surgical scars (▶Fig. 1 a, b) and a contraction ring at the lower esophagus (▶Fig. 1 c). The patient was diagnosed with type II achalasia under barium esophagography (▶Fig. 1d) and high resolution esophageal manometry. We decided to perform POEM on the patient. Briefly, a mucosal incision was made on the posterior esophageal wall (▶Fig. 2 a). Once the endoscope was maneuvered into the submucosal space, the transparent cap was applied to bluntly dissect the fibers and thus establish a submucosal tunnel (▶Fig. 2b). The blunt dissection was so efficient that it took only 2 minutes to establish a 10-cm tunnel (▶Fig. 2 c). After the submucosal tunnel was extended 2 cm into the proximal stomach, the selective inner circular myotomy and full-thickness myotomy were conducted (▶Fig. 2d). Finally, the mucosal entry was closed using endoclips (▶Fig. 2 e). After the procedure, the lower esophageal sphincter (LES) was open and the endoscope smoothly passed the cardia (▶Fig. 2 f). The simplest strategy to establish a tunnel is to dissect the submucosal fibers without a knife, and the most effective way to prevent complications is to preserve the intact mucosal flap [5]. In the current method of blunt POEM, we develE-Videos