"POSTERIOR-LIKE" ANTERIOR POEM

Per Oral Endoscopic Myotomy (POEM) can be performed via an anterior or posterior approach to the esophageal wall, depending on the operator's preference. Recent data, however, show that posterior POEM is faster in accomplishing myotomy and in mucosal closure time with less risk for inadvertent mucosal injury. These advantages are attributed to the axis of the dissection plane which naturally parallels to the endoscope working channel. Conversely, anterior POEM has been associated with less esophageal acid exposure post myotomy. Moreover, the gravity-dependent pooling of liquids occurs away from the dissection plane. Therefore, we have recently introduced a modified version of anterior POEM, named 'Posterior-Like' anterior POEM, in which the operator simulates the experience of posterior POEM while performing anterior POEM, by means of ergonomic shifts. This is done through anticlockwise rotation of the endoscope shaft, while simultaneously rotating the operator's body to face another monitor placed by the patient's feet. In this fashion, the tunnel and the myotomy axis are positioned at 6 o'clock, as in posterior POEM. The purpose of this video is to present step by step this technique in a case of type I Achalasia.