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".)
- Khashab MA, Pasricha PJ. Conquering the third space: challenges and opportunities for diagnostic and therapeutic endoscopy. Gastrointest Endosc 2013; 77:146.
- Kandulski A, Fuchs KH, Weigt J, Malfertheiner P. Jackhammer esophagus: high-resolution manometry and therapeutic approach using peroral endoscopic myotomy (POEM). Dis Esophagus 2016; 29:695.
- Khashab MA, Saxena P, Kumbhari V, et al. Peroral endoscopic myotomy as a platform for the treatment of spastic esophageal disorders refractory to medical therapy (with video). Gastrointest Endosc 2014; 79:136.
- Kristensen HØ, Bjerregaard NC, Rask P, et al. Peroral endoscopic myotomy (POEM) for nutcracker esophagus. Three cases with 12 months follow-up. Scand J Gastroenterol 2014; 49:1285.
- Louis H, Covas A, Coppens E, Devière J. Distal esophageal spasm treated by peroral endoscopic myotomy. Am J Gastroenterol 2012; 107:1926.
- Minami H, Isomoto H, Yamaguchi N, et al. Peroral endoscopic myotomy (POEM) for diffuse esophageal spasm. Endoscopy 2014; 46 Suppl 1 UCTN:E79.
- Shiwaku H, Inoue H, Beppu R, et al. Successful treatment of diffuse esophageal spasm by peroral endoscopic myotomy. Gastrointest Endosc 2013; 77:149.
- Khashab MA, Stein E, Clarke JO, et al. Gastric peroral endoscopic myotomy for refractory gastroparesis: first human endoscopic pyloromyotomy (with video). Gastrointest Endosc 2013; 78:764.
- Shlomovitz E, Pescarus R, Cassera MA, et al. Early human experience with per-oral endoscopic pyloromyotomy (POP). Surg Endosc 2015; 29:543.
- Chen WF, Li QL, Zhou PH, et al. Long-term outcomes of peroral endoscopic myotomy for achalasia in pediatric patients: a prospective, single-center study. Gastrointest Endosc 2015; 81:91.
- Familiari P, Marchese M, Gigante G, et al. Peroral endoscopic myotomy for the treatment of achalasia in children. J Pediatr Gastroenterol Nutr 2013; 57:794.
- Eckardt VF. Clinical presentations and complications of achalasia. Gastrointest Endosc Clin N Am 2001; 11:281.
- Khashab MA, Messallam AA, Saxena P, et al. Jet injection of dyed saline facilitates efficient peroral endoscopic myotomy. Endoscopy 2014; 46:298.
- Khashab MA, Kumbhari V, Kalloo AN, Saxena P. Peroral endoscopic myotomy: a 4-step approach to a challenging procedure. Gastrointest Endosc 2014; 79:997.
- Stavropoulos SN, Modayil RJ, Friedel D, Savides T. The International Per Oral Endoscopic Myotomy Survey (IPOEMS): a snapshot of the global POEM experience. Surg Endosc 2013; 27:3322.
- Minami H, Inoue H, Haji A, et al. Per-oral endoscopic myotomy: emerging indications and evolving techniques. Dig Endosc 2015; 27:175.
- Li QL, Chen WF, Zhou PH, et al. Peroral endoscopic myotomy for the treatment of achalasia: a clinical comparative study of endoscopic full-thickness and circular muscle myotomy. J Am Coll Surg 2013; 217:442.
- Von Renteln D, Fuchs KH, Fockens P, et al. Peroral endoscopic myotomy for the treatment of achalasia: an international prospective multicenter study. Gastroenterology 2013; 145:309.
- Sharata AM, Dunst CM, Pescarus R, et al. Peroral endoscopic myotomy (POEM) for esophageal primary motility disorders: analysis of 100 consecutive patients. J Gastrointest Surg 2015; 19:161.
- NOSCAR POEM White Paper Committee, Stavropoulos SN, Desilets DJ, et al. Per-oral endoscopic myotomy white paper summary. Gastrointest Endosc 2014; 80:1.
- Teitelbaum EN, Rajeswaran S, Zhang R, et al. Peroral esophageal myotomy (POEM) and laparoscopic Heller myotomy produce a similar short-term anatomic and functional effect. Surgery 2013; 154:885.
- Verlaan T, Rohof WO, Bredenoord AJ, et al. Effect of peroral endoscopic myotomy on esophagogastric junction physiology in patients with achalasia. Gastrointest Endosc 2013; 78:39.
- Vigneswaran Y, Tanaka R, Gitelis M, et al. Quality of life assessment after peroral endoscopic myotomy. Surg Endosc 2015; 29:1198.
- Werner YB, Costamagna G, Swanström LL, et al. Clinical response to peroral endoscopic myotomy in patients with idiopathic achalasia at a minimum follow-up of 2 years. Gut 2016; 65:899.
- Inoue H, Sato H, Ikeda H, et al. Per-Oral Endoscopic Myotomy: A Series of 500 Patients. J Am Coll Surg 2015; 221:256.
- Hungness ES, Sternbach JM, Teitelbaum EN, et al. Per-oral Endoscopic Myotomy (POEM) After the Learning Curve: Durable Long-term Results With a Low Complication Rate. Ann Surg 2016; 264:508.
- Marano L, Pallabazzer G, Solito B, et al. Surgery or Peroral Esophageal Myotomy for Achalasia: A Systematic Review and Meta-Analysis. Medicine (Baltimore) 2016; 95:e3001.
- Sharata A, Kurian AA, Dunst CM, et al. Peroral endoscopic myotomy (POEM) is safe and effective in the setting of prior endoscopic intervention. J Gastrointest Surg 2013; 17:1188.
- Ling T, Guo H, Zou X. Effect of peroral endoscopic myotomy in achalasia patients with failure of prior pneumatic dilation: a prospective case-control study. J Gastroenterol Hepatol 2014; 29:1609.
- Orenstein SB, Raigani S, Wu YV, et al. Peroral endoscopic myotomy (POEM) leads to similar results in patients with and without prior endoscopic or surgical therapy. Surg Endosc 2015; 29:1064.
- Boeckxstaens GE, Annese V, des Varannes SB, et al. Pneumatic dilation versus laparoscopic Heller's myotomy for idiopathic achalasia. N Engl J Med 2011; 364:1807.
- Zhou PH, Li QL, Yao LQ, et al. Peroral endoscopic remyotomy for failed Heller myotomy: a prospective single-center study. Endoscopy 2013; 45:161.
- Onimaru M, Inoue H, Ikeda H, et al. Peroral endoscopic myotomy is a viable option for failed surgical esophagocardiomyotomy instead of redo surgical Heller myotomy: a single center prospective study. J Am Coll Surg 2013; 217:598.
- Vigneswaran Y, Yetasook AK, Zhao JC, et al. Peroral endoscopic myotomy (POEM): feasible as reoperation following Heller myotomy. J Gastrointest Surg 2014; 18:1071.
- Werner YB, von Renteln D, Noder T, et al. Early adverse events of per-oral endoscopic myotomy. Gastrointest Endosc 2017; 85:708.
- Kurian AA, Bhayani NH, Reavis K, et al. Endoscopic suture repair of full-thickness esophagotomy during per-oral esophageal myotomy for achalasia. Surg Endosc 2013; 27:3910.
- Modayil R, Friedel D, Stavropoulos SN. Endoscopic suture repair of a large mucosal perforation during peroral endoscopic myotomy for treatment of achalasia. Gastrointest Endosc 2014; 80:1169.
- Li H, Linghu E, Wang X. Fibrin sealant for closure of mucosal penetration at the cardia during peroral endoscopic myotomy (POEM). Endoscopy 2012; 44 Suppl 2 UCTN:E215.
- Kumbhari V, Azola A, Saxena P, et al. Closure methods in submucosal endoscopy. Gastrointest Endosc 2014; 80:894.
- Li QL, Zhou PH, Yao LQ, et al. Early diagnosis and management of delayed bleeding in the submucosal tunnel after peroral endoscopic myotomy for achalasia (with video). Gastrointest Endosc 2013; 78:370.
- Rawlings A, Soper NJ, Oelschlager B, et al. Laparoscopic Dor versus Toupet fundoplication following Heller myotomy for achalasia: results of a multicenter, prospective, randomized-controlled trial. Surg Endosc 2012; 26:18.
- Khajanchee YS, Kanneganti S, Leatherwood AE, et al. Laparoscopic Heller myotomy with Toupet fundoplication: outcomes predictors in 121 consecutive patients. Arch Surg 2005; 140:827.
- Roman S, Kahrilas PJ. Management of spastic disorders of the esophagus. Gastroenterol Clin North Am 2013; 42:27.
- Kumbhari V, Tieu AH, Onimaru M, et al. Peroral endoscopic myotomy (POEM) vs laparoscopic Heller myotomy (LHM) for the treatment of Type III achalasia in 75 patients: a multicenter comparative study. Endosc Int Open 2015; 3:E195.
- Ko WJ, Lee BM, Park WY, et al. Jackhammer esophagus treated by a peroral endoscopic myotomy. Korean J Gastroenterol 2014; 64:370.
- Takahashi K, Sato H, Sato Y, et al. Education and Imaging. Gastroenterology: Histopathological investigation of distal esophageal spasm (DES) using per-oral endoscopic myotomy (POEM). J Gastroenterol Hepatol 2015; 30:1113.
- Khashab MA, Messallam AA, Onimaru M, et al. International multicenter experience with peroral endoscopic myotomy for the treatment of spastic esophageal disorders refractory to medical therapy (with video). Gastrointest Endosc 2015; 81:1170.
- Patti MG, Pellegrini CA, Arcerito M, et al. Comparison of medical and minimally invasive surgical therapy for primary esophageal motility disorders. Arch Surg 1995; 130:609.
- Hibbard ML, Dunst CM, Swanström LL. Laparoscopic and endoscopic pyloroplasty for gastroparesis results in sustained symptom improvement. J Gastrointest Surg 2011; 15:1513.
- Gonzalez JM, Vanbiervliet G, Vitton V, et al. First European human gastric peroral endoscopic myotomy, for treatment of refractory gastroparesis. Endoscopy 2015; 47 Suppl 1 UCTN:E135.
- Chaves DM, de Moura EG, Mestieri LH, et al. Endoscopic pyloromyotomy via a gastric submucosal tunnel dissection for the treatment of gastroparesis after surgical vagal lesion. Gastrointest Endosc 2014; 80:164.
- Bapaye A, Dubale N, Pujari R, et al. Peroral endoscopic pyloromyotomy for delayed postoperative gastroparesis. Endoscopy 2015; 47:E581.
- Chung H, Dallemagne B, Perretta S, et al. Endoscopic pyloromyotomy for postesophagectomy gastric outlet obstruction. Endoscopy 2014; 46 Suppl 1 UCTN:E345.
- Jung Y, Lee J, Gromski MA, et al. Assessment of the length of myotomy in peroral endoscopic pyloromyotomy (G-POEM) using a submucosal tunnel technique (video). Surg Endosc 2015; 29:2377.
- Khashab MA, Ngamruengphong S, Carr-Locke D, et al. Gastric per-oral endoscopic myotomy for refractory gastroparesis: results from the first multicenter study on endoscopic pyloromyotomy (with video). Gastrointest Endosc 2017; 85:123.
- 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