Per oral endoscopic myotomy (POEM) is a minimally invasive treatment that has become the first-line treatment for achalasia, and it is emerging as a therapeutic option for other esophageal spastic disorders. Although the main procedural steps are well established, myotomy technique varies according to the centre’s expertise, ranging from conventional to underwater, or from selective to full thickness. POEM is considered a safe procedure but may be associated with adverse events in up to 7.5% of cases, with some reports of capno-pericardium and cardiac arrest. Fiber laser have been used in different applications on interventional endoscopy, and more recently on POEM. This technology enables precise and direct cut without the use of conventional monopolar current.

We report the use of holmium fiber laser technology (Quanta System, Samarate, Italy) as primary treatment on four patients with different esophageal motility disorders: type 1 and type 2 achalasia, esophagogastric junction outlet obstruction and hypercontractile esophagus.

Patients’ age ranged between 47 and 77 years. The procedures were performed under general anesthesia at the endoscopy unit after multidisciplinary conference and patient informed consent. Conventional esophageal incision and submucosa tunnelling extending to the gastric cavity was performed using an ESD knife. Subsequently, under saline immersion and through an endoscopic catheter, a 365 μm holmium laser fiber was used for the myotomy (1.5-1.8 J; 10 Hz). Myotomy length varied according to the clinical indication and manometric results, from 6 to 10 cm. Selective myotomy was performed without bleeding or any other intraprocedural adverse event. All patients were admitted for 24 hours and resumed liquid diet on day 1, without adverse events. At 3-month follow-up, all patients achieved clinical remission, one continued PPI therapy for persistent reflux symptoms.

Holmium fiber laser technology appears to be an effective and safe therapeutic tool for POEM, especially due to its ease of use, precise cutting and ability to avoid bleeding during the procedure. Robust comparative studies are needed to demonstrate the advantages of using      fibre laser  over standard techniques in third-space endoscopy.