Peroral endoscopic myotomy (POEM)
- Mouen A Khashab, MD
Mouen A Khashab, MD
- Associate Professor of Medicine
- Johns Hopkins Hospital
Achalasia results from progressive degeneration of ganglion cells in the myenteric plexus in the esophageal wall. It is characterized by the failure of relaxation of the lower esophageal sphincter (LES), often accompanied by a loss of peristalsis in the distal esophagus. Treatment of achalasia is aimed at decreasing the resting pressure in the LES to allow passage of ingested material.
Achalasia can be treated with pneumatic dilatation, botulinum toxin injection, or surgical myotomy. Laparoscopic Heller myotomy is the most commonly performed surgical myotomy procedure. (See "Surgical myotomy for achalasia".)
Peroral endoscopic myotomy (POEM) is the endoscopic equivalent of surgical myotomy and a newer technique for the management of achalasia. POEM utilizes the principles of submucosal endoscopy to transform the submucosal layer in the esophagus and proximal stomach into a tunnel, through which esophageal and gastric myotomy are carried out using a flexible endoscope . Because POEM is performed perorally without any incisions in the chest or abdomen, it is a form of natural orifice transluminal endoscopic surgery (NOTES). (See "Natural orifice transluminal endoscopic surgery (NOTES)".)
The indications, contraindications, techniques, and outcomes of POEM are discussed in this topic. The clinical manifestations, diagnosis, and other treatment options of achalasia are reviewed elsewhere. (See "Achalasia: Pathogenesis, clinical manifestations, and diagnosis" and "Overview of the treatment of achalasia" and "Surgical myotomy for achalasia".)
Indications — POEM can be performed in most patients who have symptomatic, manometrically proven primary idiopathic achalasia. The diagnostic evaluation of achalasia is discussed separately. (See "Achalasia: Pathogenesis, clinical manifestations, and diagnosis".)
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- PATIENT SELECTION
- PREOPERATIVE EVALUATION
- OPERATIVE MANAGEMENT
- Preoperative preparation
- Operative technique
- - Step 1: Mucosal incision
- - Step 2: Creation of submucosal tunnel
- - Step 3: Myotomy
- - Step 4: Closure of mucosal incision
- POSTOPERATIVE CARE
- OUTCOMES OF POEM FOR ACHALASIA
- POEM for primary achalasia
- POEM for recurrent achalasia
- Adverse events
- - Pneumoperitoneum
- - Pneumothorax
- - Mucosal tear
- - Bleeding
- - Gastroesophageal reflux
- POEM FOR DISEASES OTHER THAN ACHALASIA
- POEM for spastic esophageal disorders
- POEM for gastroparesis
- - Technique of G-POEM
- - Outcomes of G-POEM for gastroparesis
- SUMMARY AND RECOMMENDATIONS