Prevention of inadvertent injury of diaphragm during posterior peroral endoscopic myotomy for achalasia cardia.

Competing Interests: Disclosure All authors disclosed no financial relationships. Commentary Albeit rare, injury to the diaphragm during POEM can have devastating consequences, and every effort should be taken to prevent injury to the diaphragm. These authors demonstrate an interesting case of inadvertent superficial injury of the diaphragm during posterior myotomy. The case highlights the importance of identifying both the circular and the longitudinal muscles during POEM, with careful selective myotomy of both these layers. In addition, performing myotomy using an outward-in approach instead of an in-outward approach can help preserve the extraluminal adventitia and avoid inadvertent injury to the surrounding organs, such as the pericardium or diaphragm. Thus, during an anterior approach, myotomy in a top-down fashion is preferred, whereas during a posterior myotomy, a down-top myotomy can be helpful. Salmaan Jawaid, MD, Assistant Professor of Medicine, Baylor College of Medicine, Houston, Texas, USA Mohamed O. Othman, MD, GIE Senior Associate Editor