Post written by Ahmad Madkour, MD, from the Endemic Medicine Department, Faculty of Medicine, Helwan University, Cairo, Hassan Atalla, MD, from the Hepatology and Gastroenterology Unit, Department of Internal Medicine, Faculty of Medicine, Mansoura University, Mansoura, and Amr Elfouly, MD, from the Endemic Medicine Department, Faculty of Medicine, Helwan University, Cairo, Egypt.

We present a novel anatomically guided approach to assist experienced endoscopists in tailoring myotomy length during peroral endoscopic myotomy for achalasia. The method relies on identifying the convergence of 3 anatomical landmarks at the esophagogastric junction (EGJ)—the esophageal adventitia, diaphragmatic crura, and perigastric peritoneum—after a full-thickness myotomy. This EGJ triad provides a clear and reproducible reference point for determining optimal myotomy length.

Once the diaphragmatic crura are reached, the myotomy is extended 2 to 3 cm beyond this point. The limitation of this method is that these landmarks can be visualized only after completing the myotomy.

Nevertheless, it remains practical in both situations: If the tunnel is longer than necessary, myotomy is stopped once the peritoneum is identified at the desired distance; if shorter, further injection and tunneling can be performed until the target length is achieved.

Educational value for endoscopists: This technique is simple, effective, and reproducible and does not require additional equipment. It may be especially appealing to experienced peroral endoscopic myotomy practitioners, as the success of the procedure hinges on accurate determination of myotomy length.

Insufficient myotomy can lead to persistent symptoms or recurrence, although excessive myotomy may increase the risk of gastroesophageal reflux.

Current methods for EGJ detection are often operator-dependent, time-consuming, and variably accurate and may require specialized accessories not always available.

Our approach provides an easily adoptable alternative that integrates seamlessly into the procedural workflow, avoiding unnecessary complexity.

Endoscopic view of diaphragmatic crura (black arrowheads) appearing as a sheet of traversing muscle fibers perpendicular to the esophageal muscular layers, with the perigastric peritoneum appearing close to it (yellow arrowheads).

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