POEM: Peroral Endoscopic Myotomy
POEM stands for Peroral Endoscopic Myotomy, which is an endoscopic procedure used for the treatment of achalasia and other esophageal motility disorders 1, 2.
Procedure Overview
POEM involves:
- Creating a submucosal tunnel 10-15 cm proximal to the lower esophageal sphincter (LES)
- Extending this tunnel 2-4 cm onto the gastric cardia
- Performing circular muscle myotomy within the tunnel 2
Clinical Applications
POEM is particularly effective for:
- Type III achalasia (92% response rate) 2
- Can be used for all achalasia subtypes with comparable efficacy to laparoscopic Heller myotomy (LHM) 1, 3
- Allows for tailored approach by calibrating the myotomy to the spastic segment identified on high-resolution manometry 2
Efficacy and Outcomes
POEM demonstrates excellent clinical outcomes:
- Clinical success (Eckardt score ≤3) in 98% of patients 4
- Significant reduction in Eckardt scores from pre-procedure (6.8±1.0) to post-procedure (1.2±0.6) 5
- Improvement in lower esophageal sphincter pressure (66% reduction) 5
- Improvement in timed barium esophagram column height (80% reduction) 5
Procedural Considerations
Important aspects of POEM implementation:
- Should be performed by experienced physicians in high-volume centers 1, 2
- Requires approximately 20-40 procedures to achieve competence 1, 6
- Has advantages over LHM including being minimally invasive, having no abdominal incisions, and allowing for rapid recovery 2
- Particularly advantageous for type III achalasia compared to other treatment modalities 1, 3
Post-Procedure Management
After POEM, patients require:
- Monitoring for at least 2 hours post-procedure to detect potential complications 2
- Consideration of proton pump inhibitor (PPI) therapy due to 10-40% rate of symptomatic gastroesophageal reflux disease (GERD) 2
- Surveillance endoscopy to monitor for reflux esophagitis, which occurs in approximately 19% of patients post-POEM 5
Potential Complications
Common adverse events include:
- Capno/pneumoperitoneum (30.6%)
- Subcutaneous emphysema (31.6%)
- Capno/pneumothorax (11.0%)
Serious complications are rare:
- Mediastinal leak (0.3%)
- Postoperative bleeding (1.1%)
- Mortality (0.09%) 5
POEM represents an important advancement in the minimally invasive treatment of achalasia, with evidence supporting its safety and efficacy when performed by appropriately trained endoscopists in suitable clinical settings.