Peroral Endoscopic Myotomy (POEM)
Peroral Endoscopic Myotomy (POEM)
Basic Structure of Article:
- 1. What is Achalasia? (Definition, Symptoms, Diagnosis, Treatment: Medical/Surgical)
- 2. What is POEM? How is it done? What are the other treatments for achalasia
- 3. Future Directions
Resource 1:
1. What is Achalasia? (Definition, Symptoms, Diagnosis, Treatment: Medical/Surgical)
- clinical symptoms: dysphagia, regurgitation, chest pain, weight loss, aspiration pneumonia
- Obstructive symptoms: dysphagia, regurgitation
- Perceptive symptoms: chest pain (heightened esophageal sensitivity)
- Other symptoms: weight loss, heartburn, nocturnal cough, aspiration
| Presenting Symptom | Patients Reporting the Symptom |
|---|---|
| Dysphagia | 82%-100% |
| Regurgitation | 76%-91% |
| Weight loss | 35%-91% |
| Chest pain | 25%-64% |
| Heartburn | 27%-42% |
| Nocturnal cough | 37% |
| Aspiration | 8% |
Associations: BMI > 30 more frequent choking or vomitting
Women type 3 more likely chest pain
average weight loss 20+/-16 lbs
Eckardt score for scoring achalasia
| Score | Weight Loss (kg) | Dysphagia | Retrosternal Pain | Regurgitation |
|---|---|---|---|---|
| 0 | None | None | None | None |
| 1 | <5 | Occasional | Occasional | Occasional |
| 2 | 5–10 | Daily | Daily | Daily |
| 3 | >10 | Each meal | Each meal | Each meal |
Diagnosis:
- Esophageal High resolution manometry: 3 subtypes
- Type I (classic) with minimal contractility in the esophageal body
- Type II with intermittent periods of panesophageal pressurization
- Type III (spastic) with premature or spastic distal esophageal contractions
- Peroral Endoscopic Myotomy (POEM) is a recent advancement in the treatment of achalasia.
- The method was initially described in the 1980s and underwent significant revision and development in the 2000s.
- Over 5000 patients have undergone the POEM procedure.
- During POEM, a submucosal tunnel is created approximately 10 cm proximal to the gastroesophageal junction, and a myotomy of circular muscle layers is extended distally to 2 cm into the cardia.
- Large European and US multicenter trials have reported short-term efficacy rates similar to those of laparoscopic Heller myotomy (LHM), with a response rate of over 90%.
- Long-term follow-up in a cohort of 500 patients showed excellent symptom control over a 3-year period, and POEM demonstrated similar efficacy in all three types of achalasia.
- POEM's ability to create a longer myotomy proximal to the lower esophageal sphincter (LES) may particularly benefit patients with type III achalasia, although further trials are needed to confirm this hypothesis.
- A retrospective study comparing POEM to standard LHM with a minimum follow-up of 3 years showed similar treatment success, reflux rates, and quality-of-life measures.
- POEM has also been found to be safe and effective in patients with persistent symptoms after LHM, although the rate of clinical success was lower than in patients without prior LHM.
Peroral endoscopic myotomy (POEM) is a minimally invasive surgical procedure used to treat primary idiopathic achalasia, a disorder that affects the esophagus and impairs its ability to move food into the stomach. Here are some important points regarding POEM and its contraindications:
Definition: POEM is a type of natural orifice transluminal endoscopic surgery (NOTES) that utilizes an endoscope to create an incision in the esophagus's inner lining and perform a myotomy (muscle cutting) to relieve the obstruction caused by achalasia.
Suitable Patients: POEM is typically performed in patients with symptomatic primary idiopathic achalasia, which is confirmed by manometric testing. These patients have difficulty swallowing, regurgitation, and other symptoms due to the failure of the lower esophageal sphincter to relax.
Previous Therapies: Previous treatments for achalasia, such as pneumatic balloon dilation (widening the esophagus using a balloon), botulinum toxin injection (to paralyze the sphincter muscle), or surgical myotomy, are not considered contraindications to undergoing POEM. In fact, POEM can be an alternative treatment option for patients who have not responded well to these therapies.
Contraindications: There are specific conditions that may make a patient ineligible for POEM. These include:
Severe erosive esophagitis: Inflammation and damage to the esophagus caused by acid reflux can affect the healing process after POEM.
Coagulation disorders: Significant blood clotting abnormalities can increase the risk of bleeding during the procedure.
Liver cirrhosis with portal hypertension: In these cases, increased pressure in the blood vessels can make the procedure more risky.
Previous therapies affecting esophageal integrity: Prior treatments that may have compromised the integrity of the esophageal mucosa or led to submucosal fibrosis, such as radiation therapy, endoscopic mucosal resection, or radiofrequency ablation, may increase the risk of complications during POEM.
The information you provided highlights various aspects of the peroral endoscopic myotomy (POEM) procedure and its applications. Here are the key points:
Length of Myotomy: For achalasia patients, a 2 to 3 cm myotomy into the gastric cardia is typically aimed for. On the esophageal side, a 6 cm myotomy is usually performed for achalasia type I and II. However, in patients with spastic esophageal disorders, the length of the myotomy should be determined based on manometric and endoscopic findings, with the inclusion of the spastic esophageal segment.
Post-Procedure Care: After undergoing POEM, patients are typically admitted to the hospital for overnight observation and kept nil per os (NPO), meaning no oral intake. The following day, an esophagram (imaging study of the esophagus) is conducted to check for any esophageal leaks. Once cleared, patients are allowed a soft diet. Upon discharge, patients are prescribed broad-spectrum antibiotics for about three days, daily proton pump inhibitors, and advised to follow a soft diet for 10 to 14 days.
Success Rates: In the short term, POEM has shown success rates ranging from 82 to 100 percent for achalasia, which are comparable to laparoscopic Heller myotomy and superior to pneumatic dilation. Longer-term studies have demonstrated success rates of 78 to 88 percent at two to five years. Additionally, POEM has been considered as a viable treatment option for patients experiencing recurrent or persistent symptoms after other achalasia treatments.
Adverse Events: Adverse events associated with POEM can include pneumoperitoneum (air in the abdominal cavity), subcutaneous emphysema (air trapped under the skin), pneumothorax (collapsed lung), mucosotomy (incision in the mucosal lining), bleeding, and gastroesophageal reflux. However, the incidence of adverse events is relatively low, around 8 percent, and most of these events can be managed expectantly, medically, or through endoscopic interventions.
Additional Applications: Apart from treating achalasia, the POEM technique has been successfully used to address other conditions such as spastic esophageal disorders (spastic achalasia, distal esophageal spasm, jackhammer esophagus, nutcracker esophagus), severe gastroparesis (G-POEM), and Zenker's diverticula (Z-POEM).
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