Peroral endoscopic myotomy assisted with an elastic ring for achalasia with obvious submucosal fibrosis: A case report

Figure 1 Preoperative esophagography. A: Preoperative esophagography revealed severe esophageal dilatation and no obvious passage of barium. A Preoperative esophagography revealed severe esophageal dilatation and no obvious passage of barium; B: Postoperative esophagography demonstrated a rapid passage of barium from the esophagus into the stomach; C: The lamina was closed preoperatively; D: Mucosal uplift was poor after submucosal injection of 20-mL epinephrine meilan saline; E: Submucosal lift was poor after mucosal myotomy; F: Submucosal adhesion was obvious, and submucosal tunnel could not be established; G: The elastic traction ring was fixed at the tunnel opening; H: A second clip was placed to attach the ring to the opposing esophageal wall to create tension. The submucosa was exposed by means of traction of the elastic traction ring, and submucosal adhesion was obvious; I: Submucosal tunnel was established.