Dislodged hood stuck in submucosal tunnel: retrieval during peroral endoscopic myotomy

Abstract

A 42-year-old man with type II achalasia cardia underwent peroral endoscopic myotomy (POEM) by posterior approach. The procedure was started using a gastroscope fitted with a conical hood (DH-28GR, Fujifilm, Tokyo, Japan). The gastroesophageal junction (GEJ) was tight when the scope reached the lower end during the creation of the submucosal tunnel. The scope was maneuvered to pass beyond the GEJ. However, the hood became stuck at the tight GEJ and slipped off the gastroscope. During an attempt to remove the hood using a rat-tooth forceps, one portion of the hood chipped off ([Fig. 1]). The hood was tightly stuck in the submucosal tunnel and the mucosa prolapsed inside the tunnel ([Fig. 2]). Forceful removal of the hood could have caused mucosal injury.