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Peroral endoscopy myotomy (POEM) is a highly efficacious endoscopic treatment for achalasia. Conventionally, a submucosal tunnel is fashioned in the anterior or 2 o’clock position of the esophagus. There are occasional failed POEM cases, especially in patients with significant fibrosis or scarring of submucosa from prior therapies, such as botulinum toxin injection. This video describes the case of a patient with achalasia who had an incomplete clinical response to an anterior POEM procedure because of significant fibrosis of the esophagus from prior achalasia therapies. To further treat her symptoms, we offered a salvage posterior POEM procedure in which we created a second submucosal tunnel in the 5 o’clock position (Fig. 1; Video 1, available online at www.giejournal.org). The patient’s clinical symptoms and Eckardt Scale score improved (from 7 to 4) after this procedure. Posterior POEM has a higher theoretical risk because of the proximity of the posterior esophagus to vascular structures; however, it lends itself to easier closure of the mucosal incision with endoscopic suturing because of the orientation of the instrument channels of the endoscope. In patients with failed anterior POEMs, performance of a posterior POEM is a reasonable option to increase the likelihood of clinical success. However, this technique should be attempted by endoscopists with significant experience in performing POEM.

Background : Hypopigmented macules have been described infrequently as a presenting form of mycosis fungoides (MF). Objective : This study was designed to clarify general characteristics of a hypopigmented MF variant. Methods : Seven new cases were investigated with the use of descriptive epidemiology techniques. Demographic parameters, histopathology, and treatment outcomes were analyzed. These data were combined with those from prior reports to develop a broad composite view of this disease process. Results : The median ages in our series were 36 years for disease onset and 39 years at biopsy diagnosis. All patients had brown or black skin. Histologic findings consistently showed a lack of epidermal atrophy and moderate to profound exocytosis. Treatment with PUVA induced rapid and complete repigmentation in six of seven patients. Conclusion : On the basis of our experience and a literature review, the hypopigmented variant of MF occurs in a younger population than typical forms of the disease and affects persons with dark skin almost exclusively. Microscopic features include lack of epidermal atrophy and moderate to extreme epidermotropism of infiltrating mononuclear cells. The treatment of choice appears to be PUVA.

Background: Anorectal manometry is useful in evaluating and planning treatment in patients with fecal incontinence (FI) and other disorders of defecation. Traditional water perfusion techniques are limited to 4 to 8 radial measurements obtained via a pullback technique. Three-dimensional high resolution anorectal manometry (3D HRAM) employs solid state micro transducers and can obtain 257 data points during resting, squeeze, and bear down (simulated defecation) sequences. Data are then reconstructed into a 3D format showing functional anatomy. While differences are known to exist between patients with FI and obstruction, patients with mixed disorders (of FI and obstruction) are less well described Objective: To determine physiologic differences between groups of female patients with FI, obstructed defecation, and mixed disorders. In addition to known parameters of mean resting pressure and maximal squeeze pressure, relationships between rectoanal pressure differential and percent anal relaxation were sought among the groups. Methods Retrospective chart review of 50 female patients undergoing 3D HRAM between 1/1/ 13 and 6/1/14. Physiologic values including mean resting, and maximal squeeze pressures, percent anal relaxation, and rectoanal pressure differential were recorded. Analysis of variance test, and linear regression analysis was performed as appropriate. Results:Women with mixed defecatory disorders had sphincter pressure profiles that were significantly different from patients with pure FI or obstruction (table). While rectoanal pressure differential was not different among the groups, patients with mixed disorders had a significant linear relationship between rectoanal pressure differential and percent anal relaxation that was not seen among the pure FI or obstructed groups (figure). Conclusion: Mixed defecatory disorders are associated with a unique physiologic profile that can be characterized using 3D HRAM. The mixed defecatory group demonstrates relationships between physiologic parameters that are not seen the incontinent or obstructed groups. This data will be helpful in the planning treatment regimens.

Objectives : To describe the technique of pneumatic dilation for achalasia without fluoroscopic guidance and to assess its safety and efficacy. Methods : Twenty-seven consecutive patients who underwent pneumatic dilation with the Rigiflex achalasia balloon under direct endoscopic visualization were reviewed. The balloon was passed into the stomach over a guidewire, withdrawn across the gastroesophageal junction, and dilated with the endoscope positioned proximally. Patients were graded pre- and posttreatment on the frequency of dysphagia, daytime regurgitation, nighttime symptoms, chest pain, and heartburn. Response was assessed by the improvement in dysphagia frequency. Results : Twenty-seven patients (16 females, 11 males ; mean age 54.0 yr) underwent 30 pneumatic dilations. The 30-mm balloon was used in most cases (67%). The mean postdilation follow-up was 21.1 months (1.5-57.4 months). The range of inflation pressures was 8-18 psi (median 15 psi), and the duration of inflation was 30-120 s (median 90 s). Eighteen of 27 patients (67%) had excellent or good results, six (22%) had fair results, and three (11%) had poor results. The outcome of pneumatic dilation was successful in 78% of patients after a single dilation and in 89% of patients overall. There were no perforations related to balloon inflation. Conclusions : The Rigiflex balloon can be successfully positioned across the gastroesophageal junction and dilated under direct endoscopic observation. Pneumatic dilation for achalasia can therefore be performed simply, safely, and effectively without the use of fluoroscopy.