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Background During peroral endoscopic myotomy (POEM), use of traditional instruments leads to an increase in overall time of procedure due to constant exchange of instruments. Speedboat-RS2 (Creo-Medical, UK) is a novel device which has shown promising results for endoscopic submucosal dissection of gastrointestinal lesions, but its feasibility, and safety for POEM is unexplored. Methods Data from patients who had undergone POEM for achalasia cardia utilizing Speedboat-RS2 was reviewed. Results Two patients with mean age of 46 years and mean symptom duration of 3 years were included. Both patients had type II achalasia diagnosed on esophageal manometry. One patient underwent anterior myotomy and the other posterior approach. Submucosal tunneling (~15 cm) was achieved in a mean of 20 minutes, myotomy (~ 9 cm) in 8 minutes and the entire procedure was completed in a mean of 30 minutes with 100 % technical success. Both patients were discharged the day after the procedure without any immediate adverse events. At 6 weeks, endoscopy was uneventful and the patients were asymptomatic. Conclusions Early experience shows that Speedboat-RS2 is feasible for performing POEM with good safety profile. Submucosal tunneling was relatively quick and coagulation was effective. Long term studies with a larger patient cohort are warranted.

Background and aims EUS-guided biliary drainage (EUS-BD) and rendezvous (EUS-RV) are acceptable rescue options for patients with failed endoscopic retrograde cholangiopancreatography (ERCP). However, there are limited training opportunities at most centers owing to low case volumes. The existing models do not replicate the difficulties encountered during EUS-BD. We aimed to develop and validate a model for stepwise learning of EUS-BD and EUS-RV, which replicates the actual EUS-BD procedures. Methods A hybrid model was created utilizing pig esophagus and stomach, with a synthetic duodenum and biliary system. The model was objectively assessed on a grade of 1 – 4 by two experts. Twenty-eight trainees were given initial training with didactic lectures and live procedures. This was followed by hands-on training in EUS-BD and EUS-RV on the hybrid model. Trainees were assessed for objective criteria of technical difficulties. Results Both the experts graded the model as very good or above for all parameters. All trainees could complete the requisite steps of EUS-BD and EUS-RV in a mean time of 11 minutes (8 – 18 minutes). Thirty-six technical difficulties were noted during the training (wrong scope position, 13; incorrect duct puncture, 12; guidewire related problems, 11). Technical difficulties peaked for EUS-RV, followed by hepaticogastrostomy (HGS) and choledochoduodenostomy (CDS) (20, 9, and 7, P = 0.001). At 10 days follow-up, nine of 28 trainees had successfully performed three EUS-RV and seven EUS-BD procedures independently. Conclusions The Mumbai EUS II hybrid model replicates situations encountered during EUS-RV and EUS-BD. Stepwise mentoring improves the chances of success in EUS-RV and EUS-BD procedures.