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. 2021 Aug 16;9(9):E1335–E1341. doi: 10.1055/a-1499-6817

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The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License, which permits unrestricted reproduction and distribution, for non-commercial purposes only; and use and reproduction, but not distribution, of adapted material for non-commercial purposes only, provided the original work is properly cited.

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Fig. 1 — Submucosal tunneling in cases with varying severity of submucosal fibrosis (SMF). a Submucosal tunnelling in a case with no SMF. b, c, d SMF with loose adherence of mucosa and muscle layer. Note that POEM could be completed using the same tunnel. e, f Severe SMF with complete adherence of mucosa and muscle layer. double tunnel POEM was performed in these cases.