1. Per-oral endoscopic myotomy, 1000 cases later: pearls, pitfalls, and practical considerations 
Robert Bechara, MD, Manabu Onimaru, MD, PhD, Haru Ikeda, MD, Haruhiro Inoue, MD, PhD 
Gastrointestinal Endoscopy 
Volume 84, Issue 2, Pages (August 2016)
DOI: /j.gie
Copyright © 2016 American Society for Gastrointestinal Endoscopy Terms and Conditions

2. Figure 1
Important luminal landmarks in POEM. A, Upper esophageal sphincter. B, Left main bronchus (blue dot/arrow). C, Aortic arch (red dot/arrow) and spine (white dot/arrow). D, Aortic arch (red dot), spine (white dot), and left main bronchus (blue dot). E, Abnormal nonperistaltic contraction in mid-esophagus. F, Gastroesophageal junction.
Gastrointestinal Endoscopy  , DOI: ( /j.gie )
Copyright © 2016 American Society for Gastrointestinal Endoscopy Terms and Conditions

3. Figure 2
Injection catheters used in POEM. Spray catheter (Olympus PW-5V-1) (A) and injection needle (Olympus NM 400L-0425) (B).
Gastrointestinal Endoscopy  , DOI: ( /j.gie )
Copyright © 2016 American Society for Gastrointestinal Endoscopy Terms and Conditions

4. Figure 3
Recognition and correction of tunnel shifting. The dotted line indicates the muscle–submucosa interface. A, Tunnel progressing straight (green arrows) in correct orientation. B, Tunnel shifting excessively to the right. To correct for the shift, the left side should be dissected (green arrows) until fibers are perpendicular to the endoscope. C, Tunnel shifting excessively to the left. To correct for shift, the right side should be dissected (green arrows) until fibers are perpendicular to the scope.
Gastrointestinal Endoscopy  , DOI: ( /j.gie )
Copyright © 2016 American Society for Gastrointestinal Endoscopy Terms and Conditions

5. Figure 4
Early splitting of the circular muscle fibers during tunnel formation. A, Recognition of early splitting of circular muscle fibers. B, Injection above the muscle into submucosa. C, Expansion of submucosa, pushing the circular muscle away from the mucosa and preventing dissection into intermuscular space. D, A case with fibrosis with entry into the intermuscular space during tunneling. E, After coagulation of the perforating artery, the submucosa was carefully dissected to restore the correct plane of dissection (note poor delineation of tissue planes with fibrosis). F, Recovery of correct plane of submucosal tunnel.
Gastrointestinal Endoscopy  , DOI: ( /j.gie )
Copyright © 2016 American Society for Gastrointestinal Endoscopy Terms and Conditions

6. Figure 5
Two general approaches for selective myotomy showing the distal bending section of the scope in the submucosal tunnel. A, Muscle at the 6 o’clock position (usual position for posterior myotomy). B, Muscle at the 12 o’clock position (usual position for anterior myotomy). The blue arrow indicates the degree of potential “fling” that can occur with each technique. Note that generally more tip angulation is required for the anterior myotomy.
Gastrointestinal Endoscopy  , DOI: ( /j.gie )
Copyright © 2016 American Society for Gastrointestinal Endoscopy Terms and Conditions

7. Figure 6
Transillumination method demonstrating the position of the distal myotomy. A, Ultra-slim gastroscope in the tunnel and regular gastroscope in the stomach. B, Regular gastroscope in the tunnel and ultra-slim gastroscope in the stomach.
Gastrointestinal Endoscopy  , DOI: ( /j.gie )
Copyright © 2016 American Society for Gastrointestinal Endoscopy Terms and Conditions

8. Figure 7
Closure of the mucosal entry site. A, Asymmetric deployment of the first clip. B, Result of excessive tissue captured on the left, creating a problematic tissue fold. To correct for this, the next clip should grasp more tissue on the right side. C, Correct symmetric deployment of first clip. D, Equal-sized tissue fold on either side of clip, allowing easy symmetric application of the subsequent clip.
Gastrointestinal Endoscopy  , DOI: ( /j.gie )
Copyright © 2016 American Society for Gastrointestinal Endoscopy Terms and Conditions

9. Figure 8
Bleeding at the gastroesophageal junction. A, Triangle tip knife approaching the vessel. B, Vessel transected and inability to achieve hemostasis with coagulation with Triangle tip knife. Observe ensuing brisk bleeding and red-out. C, Tamponading of the vessel with a transparent hood with gentle advancement of the scope. D, The severed vessel is easily visualized and coagulated with coagulation forceps.
Gastrointestinal Endoscopy  , DOI: ( /j.gie )
Copyright © 2016 American Society for Gastrointestinal Endoscopy Terms and Conditions