From the Guidelines
Peroral endoscopic myotomy (POEM) is a minimally invasive procedure that involves making a mucosal incision and creating a submucosal tunnel to perform a myotomy of the lower esophageal sphincter (LES) using endoscopy, allowing for the treatment of achalasia with a success rate of over 90%. This procedure has gained widespread adoption due to its technical advantages over laparoscopic Heller myotomy (LHM), including the lack of abdominal incisions, more rapid recovery, and the option of avoiding general anesthesia with airway intubation 1. The POEM procedure involves extending a submucosal tunnel distally 2–4 cm onto the gastric cardia using a standard endoscope and electrocautery, and then achieving a circular muscle myotomy from within the submucosal tunnel 1.
Some of the key benefits of POEM include:
- Lack of abdominal incisions
- More rapid recovery
- Option of avoiding general anesthesia with airway intubation
- Ease of performing a longer myotomy if desired
- Avoidance of vagal nerve injury
- Lack of intra-abdominal adhesions that might hinder future surgery However, potential complications of POEM include:
- Perforation
- Pneumothorax
- Bleeding
- Gastroesophageal reflux disease (GERD), which is observed in up to 58% of patients 1
The success rate of POEM has been reported to be over 90% in multiple uncontrolled studies, with significant reduction in Eckardt scores and LES pressures at 2 months, 1 year, and 3 years post-procedure 1. A recent systematic review and meta-analysis comparing outcomes of POEM and LHM found POEM to be more effective than LHM in relieving dysphagia in the short term, but associated with a very high incidence of pathologic reflux 1. Overall, POEM is a safe and effective management option for achalasia, but patients should be advised beforehand that they might require lifelong proton pump inhibitor therapy for symptomatic reflux or erosive esophagitis.
From the Research
Definition and Overview of Peroral Endoscopic Myotomy (POEM)
- Peroral endoscopic myotomy (POEM) is a novel technique within the field of third space endoscopy 2.
- The procedure involves the creation of a mucosal incision, careful dissection of the submucosal space, performing a controlled myotomy, and finally, closure of the mucosal incision 2.
- POEM was initially developed for the management of achalasia and has since expanded to include other benign upper gastrointestinal (GI) pathologies such as cricopharyngeal bar, Zenker's diverticulum, esophageal diverticula, and gastroparesis 2.
Technical Aspects and Indications of POEM
- The technical aspects of POEM involve the use of an electrosurgical knife to reach the muscularis and perform a controlled myotomy 2.
- The indications for POEM have expanded to include a range of benign upper GI pathologies, including achalasia, cricopharyngeal bar, Zenker's diverticulum, esophageal diverticula, and gastroparesis 2, 3.
- POEM offers a minimally invasive alternative to surgical intervention with high clinical success and low rate of adverse events 2, 3, 4, 5.
Efficacy and Safety of POEM
- Studies have shown that POEM is a safe and effective treatment for achalasia and other esophageal motility disorders, with significant improvements in objective metrics and symptom-related scores 3, 4, 5.
- The procedure has been shown to descrease lower esophageal sphincter pressure and improve esophageal emptying, with a median hospital length of stay of 1 day and an overall morbidity rate of 6% 3.
- POEM has also been compared to laparoscopic Heller's myotomy, with similar results in terms of adverse events and operative time, and a trend towards a reduced length of hospital stay in the POEM group 4.