What is the role of Peroral Endoscopic Myotomy (POEM) in treating achalasia?

From the Guidelines

POEM (Per-Oral Endoscopic Myotomy) is a highly effective treatment for achalasia, particularly for type III achalasia, and may be considered as a first-line treatment option for most patients. The procedure involves creating a submucosal tunnel in the esophagus and selectively cutting the circular muscle fibers of the lower esophageal sphincter (LES) to relieve the obstruction. Key steps of POEM include:

• Mucosal incision (2-3 cm long) in the mid-esophagus
• Submucosal tunnel creation extending 2-3 cm below the LES
• Myotomy of circular muscle fibers, starting 2-3 cm distal to the mucosal entry and extending 2-3 cm onto the gastric cardia
• Closure of the mucosal entry site with endoscopic clips Post-procedure care includes:

• Clear liquid diet for 24 hours, then gradual advancement
• Proton pump inhibitor (e.g., omeprazole 40 mg daily) for 4-8 weeks
• Follow-up endoscopy at 2-3 months POEM is effective because it directly addresses the underlying pathophysiology of achalasia by disrupting the dysfunctional LES, allowing food and liquids to pass more easily into the stomach, as supported by recent studies 1. The procedure's minimally invasive nature results in faster recovery and fewer complications compared to traditional surgical approaches. Additionally, POEM may be superior to pneumatic dilation for patients with failed initial POEM or laparoscopic Heller myotomy, as noted in a recent expert review 1.

The decision to perform POEM should be based on shared decision making between the patient and physician, taking into account risk of post-procedural reflux, need for repeat interventions, patient preferences, and local expertise, as recommended by recent guidelines 1. Patients with esophagogastric outflow obstruction alone and/or non-achalasia spastic disorders on manometry should undergo a comprehensive evaluation, and POEM should only be considered on a case-by-case basis after other less invasive approaches have been exhausted, as suggested by recent studies 1.

Overall, POEM is a safe and effective approach for patients with achalasia, and its role in treating the condition continues to evolve based on emerging evidence and expert recommendations 1.

From the Research

Role of POEM in Treating Achalasia

• POEM is a novel minimally invasive technique that has emerged as the preferred option for the treatment of achalasia and spastic esophageal disorders (SED) at many centers around the world 2.
• POEM is a safe and effective therapy for patients with achalasia and SED, comparable to Heller myotomy (HM) in terms of safety, efficacy, and complications, including gastroesophageal reflux disease (GERD) 2, 3.
• Outcomes of POEM are excellent even in patients who had prior failed therapies for achalasia, including failed HM and prior POEM 2, 4.
• POEM is effective for both treatment-naïve patients and those with prior treatment failure, with comparable technical and clinical success rates 4.
• Retreatment with POEM or laparoscopic Heller myotomy has a higher efficacy than retreatment with pneumatic dilatations in patients with persistent or recurrent symptoms after failed POEM 5.
• POEM has similar outcomes to laparoscopic Heller's myotomy (LHM) in terms of reduction in Eckhart's score, post-operative pain scores, and analgesic requirements, length of hospital stay, adverse events, and symptomatic gastroesophageal reflux/reflux esophagitis 6.

Efficacy and Safety of POEM

• POEM has been shown to be effective in reducing Eckhart's score and lower esophageal sphincter (LES) pressure in patients with achalasia 6.
• The efficacy and safety of POEM have been demonstrated in both pediatric and geriatric patients 2.
• GERD after POEM is common, but the majority of patients are asymptomatic, highlighting the need for ongoing research and long-term surveillance of these patients 2, 3.

Comparison with Other Treatments

• POEM has been compared to other treatments such as laparoscopic Heller myotomy (LHM) and pneumatic dilation (PD), with similar outcomes in terms of efficacy and safety 3, 6.
• POEM has been shown to have a faster recovery time and less procedural pain compared to LHM 3.
• Retreatment with POEM or LHM has a higher efficacy than retreatment with PD in patients with persistent or recurrent symptoms after failed POEM 5.