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Peroral endoscopic myotomy (POEM) is an established therapy [1–3]. We describe a new technique for POEM using a slim/pediatric endoscope, which aims to provide a less-invasive approach compared with traditional POEM. A 16-year-old girl was diagnosed with achalasia based on symptoms (dysphagia, regurgitation, 6-kg weight loss over 4 months, Eckardt score of 7), barium swallow showing mildly dilated esophagus with retention of contrast (▶Fig. 1), and manometry demonstrating increased lower esophageal sphincter relaxation pressure of 13.1mmHg. POEM was initiated using a standard gastroscope. A submucosal cushion was made with succinyl gelatin-methylene blue solution 8.0 cm proximally to the gastroesophageal junction. The endoscope was exchanged for a slim gastroscope (EG-530NW, 5.9mm external outer diameter, 2.0mm working channel; Fujifilm, Tokyo, Japan), fitted with a cap cut from the tip of a 5.5mm endotracheal tube (Solidor; Well Lead Medical Co., Ltd, Guangzhou, China) (▶Fig. 2). A mucosal opening was made with the tip of an oval 13-mm polypectomy snare (Profile Snare; Boston Scientific, Marlborough, Massachusetts, USA), which was also used for the creation of the submucosal tunnel and myotomy (▶Fig. 3 a, ▶Video1). A submucosal tunnel was dissected for 2.0 cm distally to the gastroesophageal junction. When further submucosal injection was needed, we utilized a 22-gauge needle (Injectra; MediGlobe, Achenmühle, Germany) by removing the needle and outer sheath, and using the inner sheath as an injection device. Myotomy was then performed from 2.0 cm below the mucosal opening to the ▶ Fig. 1 Barium swallow demonstrating a mildly dilated esophagus with retention of contrast. ▶ Fig. 2 Slim gastroscope fitted with the transparent cap cut from the tip of an endotracheal tube.

Less invasive than minimally invasive: peroral endoscopic myotomy with a slim scope in the treatment of esophageal achalasia