Post written by Georgios Mavrogenis, MD, from the Department of Gastroenterology, Mediterraneo Hospital, Athens, Greece.

Endoscopists are free to choose between anterior of posterior based on their preference. Recent data illustrate that posterior POEM is faster and less prone to mucosal injuries. Conversely, some studies have associated anterior POEM with less post-myotomy acid reflux. We tried to combine the advantages of both techniques in a single procedure that simulates the endoscopic view of posterior POEM. The concept is simple: the procedure begins as an anterior POEM, but after a few cm of tunneling the shaft of the endoscope is rotated and the myotomy line is placed at 6 o’clock. In this way the endoscopic image is identical to posterior POEM, and the procedure is completed in this way.

In order to perform PL-POEM, we need a second monitor placed by the patient’s feet. Besides that, there is no additional equipment necessary. This technical tip can be useful for faster and safer anterior myotomy of the esophageal body. The major drawback of this approach is that in case of acute angulation of the cardia, the myotomy becomes challenging and the standard anterior approach should be preferred.

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