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A 60-year-old man was referred complaining of dysphagia, retrosternal pain, and regurgitation after each meal over the previous 6 years, his symptoms having worsened in the previous year. He was diagnosed with achalasia following examination that included an esophagography (●" Fig.1). We treated him by performing peroral endoscopic myotomy (POEM) [1]. With the patient under general anesthesia and in the supine position, a submucosal cushion was created on the anterior esophageal wall (2 o’clock position) using a mixture of glycerol solution and 0.01% epinephrine with indigo carmine, after a vertical mucosal incision had been made with a triangular tip knife (KD640L; Olympus Optical). A gastroscope was subsequently inserted into the submucosal space, and dissection was performed to create a submucosal tunnel that extended 3cm beyond the esophagogastric junction (●" Fig.2a, ●" Fig.2b). We subsequently performed selective myotomy of the inner circular muscle from the esophagus to the gastric cardia (●" Fig.2c). Neither remarkFig.2 Endoscopic views showing: a the submucosal tunnel ending in the gastric cardia; b in reverse view, a blue mucosa over the gastric cardia, indicating where the submucosal tunnel extended beyond the esophagogastric junction; c selective cutting of the circular muscle bundles from the longitudinal muscle using a triangular tip knife; d acute ischemic ulcers over the gastric cardia, which were observed after the procedure had been completed.

Acute gastric mucosal ischemic ulcer: a rare adverse result of peroral endoscopic myotomy