title: Retrograde myotomy: a variation in per oral endoscopic myotomy (POEM) technique.
abstract: BACKGROUND
  Per oral endoscopic myotomy (POEM) has evolved as a novel therapeutic option for the treatment of esophageal motility disorders such as achalasia. The originally described dissection technique involves cutting the inner circular esophageal muscle fibers in an antegrade fashion. We have modified this technique by commencing the muscular division at the most distal aspect of the submucosal tunnel and continuing the dissection in a retrograde fashion. We present our initial series of patients performed using this modified technique.
  
  
  METHODS
  We retrospectively reviewed our prospectively collected database. Peri- and postoperative data were collected and analyzed. POEM procedures were performed in a near-identical manner as previously published.
  
  
  RESULTS
  Retrograde myotomy was performed on five patients with a diagnosis of achalasia. Four had a history of prior treatment including balloon dilation, with one of these having a prior surgical myotomy. Retrograde POEM procedures were performed with trace blood loss and without any complications. Mean operative time was 85 min. All patients had normal esophagram studies, and diets were advanced as per protocol.
  
  
  CONCLUSIONS
  POEM was developed as a minimally invasive method for the treatment of achalasia. Our retrograde dissection modification allows the most critical portion of the case, namely division of the lower esophageal and upper gastric circular muscle fibers, to be performed earlier in the case. This ensures adequate dissection of the primary site of esophageal dysfunction should problems arise during the procedure. The modification is straightforward, without the need for additional training or equipment, and appears to provide a more rapid myotomy with less charring in this small cohort of patients.
authors.affiliation: Department of Surgery, University Hospitals Case Medical Center, Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH, 44106, USA, JPonsky@yahoo.com.
authors.forename: Jeffrey L
authors.initials: JL
authors.lastname: Ponsky
authors.forename: Jeffrey M
authors.initials: JM
authors.lastname: Marks
authors.forename: Sean B
authors.initials: SB
authors.lastname: Orenstein
mesh_terms: D004210:Dissection / Q000379:methods*; D004935:Esophageal Diseases / Q000601:surgery*; D004947:Esophagus / Q000601:surgery*; D005500:Follow-Up Studies; D006801:Humans; D009055:Mouth; D009130:Muscle, Smooth / Q000601:surgery; D057605:Natural Orifice Endoscopic Surgery / Q000379:methods*; D012189:Retrospective Studies