title: Per-oral endoscopic myotomy, 1000 cases later: pearls, pitfalls, and practical considerations.
abstract: OBJECTIVE
  Eight years have passed since the introduction of the per-oral endoscopy myotomy (POEM) procedure. POEM was initially received as an investigational procedure, but since the revelation of promising safety and efficacy data, it is becoming the preferred treatment for achalasia. With the recent completion of our 1000th POEM procedure, we share our experience and knowledge through the discussion of clinical pearls, pitfalls, and practical considerations.
  
  
  METHODS
  The various aspects of the procedure and conditions that warrant special attention are discussed from our perspective, with a focus on areas in which there is currently limited evidence.
  
  
  RESULTS
  The key points on patient position, submucosal tunneling, myotomy, closure, intraprocedural bleeding, and advanced sigmoid achalasia are presented.
  
  
  CONCLUSIONS
  The dissemination of this information serves as a foundation for new POEM operators and as a catalyst for more-experienced operators to further refine and advance their POEM skills and stimulate international discourse and collaboration.
authors.affiliation: Digestive Diseases Center, Showa University, Koto-Toyosu Hospital, Koto-Ku, Tokyo, Japan; Gastrointestinal Diseases Research Unit, Queen University Kingston General Hospital, Kingston, Ontario, Canada.
authors.forename: Robert
authors.initials: R
authors.lastname: Bechara
authors.affiliation: Digestive Diseases Center, Showa University, Koto-Toyosu Hospital, Koto-Ku, Tokyo, Japan.
authors.forename: Manabu
authors.initials: M
authors.lastname: Onimaru
authors.affiliation: Digestive Diseases Center, Showa University, Koto-Toyosu Hospital, Koto-Ku, Tokyo, Japan.
authors.forename: Haru
authors.initials: H
authors.lastname: Ikeda
authors.affiliation: Digestive Diseases Center, Showa University, Koto-Toyosu Hospital, Koto-Ku, Tokyo, Japan.
authors.forename: Haruhiro
authors.initials: H
authors.lastname: Inoue
mesh_terms: D059925:Anatomic Landmarks; D016063:Blood Loss, Surgical; D004931:Esophageal Achalasia / Q000601:surgery*; D015155:Esophageal Spasm, Diffuse / Q000601:surgery; D049630:Esophageal Sphincter, Lower / Q000601:surgery*; D004943:Esophagogastric Junction / Q000601:surgery; D004945:Esophagoscopy / Q000295:instrumentation / Q000379:methods*; D006801:Humans; D059032:Learning Curve; D057605:Natural Orifice Endoscopic Surgery / Q000295:instrumentation / Q000379:methods*; D056888:Patient Positioning; D058106:Wound Closure Techniques