Per-oral endoscopic myotomy

The per-oral endoscopic myotomy, or POEM, is a minimally invasive surgical procedure for the treatment of achalasia wherein the inner circular muscle layer of the lower esophageal sphincter is divided through a submucosal tunnel.[1] This enables food and liquids to pass into the stomach, a process that is impaired in achalasia. The tunnel is created, and the myotomy performed, using a flexible endoscope, meaning the entire procedure can be done without external incisions.

History & development

Achalasia, a disease characterized by impaired esophageal peristalsis and failure of the lower esophageal sphincter to relax, has classically been treated endoscopically by dilation or botulinum toxin injection of the sphincter or surgically by a myotomy in which the muscle fibers are cut through a thoracic or abdominal approach.[1] The principles of an endoscopic surgical myotomy were developed in the 2000s on animal models.[2] The first endoscopic myotomy was performed on human patients by H. Inoue in Tokyo, Japan in 2008 who then coined the acronym POEM.[3] It has since become increasingly popular internationally as a first-line therapy in patients with achalasia.[4]

Procedure

POEM is a form of natural orifice translumenal endoscopic surgery, or NOTES. Like the traditional surgical myotomy, the procedure is performed under general endotracheal anesthesia. The remainder of the procedure is performed using a flexible endoscope inserted through the mouth, and no cuts are made on the chest or abdomen. Occasionally, an “overtube” is inserted to facilitate repeated removal & insertion of the endoscope.[5] First, a submucosal injection of dyed saline creates a cushion, then a cut is made in the esophageal mucosa using electrocautery roughly 13 centimeters before the lower esophageal sphincter.[6] Then, using hydrostatic dissection and electrocautery, the submucosal tunnel is made. Once the circular fibers of the lower esophageal sphincter are encountered, they are divided using electrocautery all the way down onto the first part of the stomach. This functionally weakens the sphincter, allowing improved passage of food and liquid into the stomach. Finally, the submucosal flap is closed using clips or sutures also placed through the endoscope.

The procedure takes roughly 2 hours but can vary on physician and patient characteristics. Patients usually spend 1–3 days in the hospital before going home, and usually undergo a swallow study prior to resuming oral feeding.[7] Patients may return to work and full activity immediately upon discharge from the hospital. Long-term patient satisfaction is similar following POEM compared to standard laparoscopic Heller myotomy.[8]

Risks & complications

Major complications are rare after POEM and include esophageal perforation and bleeding.[9] Escape of air introduced through the endoscope into the surrounding tissues is a common occurrence and rarely requires additional intervention.[9]

The major long term risk after POEM is new or worsened gastroesophageal reflux disease, which arises in 20-46% of patients.[9] This phenomenon is usually mild and manageable with medication alone, and does not occur at a significantly higher rate than in patients undergoing a traditional surgical therapy.[10] Incomplete myotomy resulting in a persistence of symptoms is also described and requires repeating the procedure.

Cost

As of March, 2017, POEM is classified as an experimental therapy in the United States and is not reimbursed by insurance providers. Recent investigations have demonstrated both equivalency[11] and superiority [12] of POEM compared to laparoscopic Heller myotomy.

Future directions

POEM has been established as a safe and efficacious treatment for achalasia and is becoming increasingly popular as a first line alternative to conventional laparoscopic myotomy.[4] A randomized, controlled trials comparing the two procedures will be published soon as the abstract had been presented during UEGW 2018. This procedure also requires extensive training in advanced endoscopy and a knowledge of the surgical anatomy of the alimentary tract. Currently, many international conferences and post-graduate fellowships in both surgery and gastroenterology specialize in training physicians to perform POEM.

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References
  1. Chua Sk, Chiu CH; Tai, WC; Lee, JH; Lu, HI; Changchien, CS; Tseng, PH; Wu, KL (Sep 2013). "Current status in the treatment options for esocphageal achalasia". World J of Gastro. 19 (33): 5421–5429.
  2. Pasricha, PJ; Hawari, R; Ahmed, I; Chen, J; Cotton, PB; Hawes, RH; Kalloo, AN; Kantsevoy, SV; Gostout, CJ (2007). "Submucosal endoscopic esophageal myotomy: a novel experimental approach for the treatment of achalasia". Endoscopy. 39: 761–764. doi:10.1055/s-2007-966764.
  3. Inoue H, Kudo SE. Per-oral endoscopic myotomy (POEM) for 43 consecutive cases of esophageal achalasia. Nihon Rinsho. 2010 Sep;68(9):1749-52
  4. Tuason, J; Inoue, H (Apr 2017). "Current status of achalasia management: a review on diagnosis and treatment". J Gastroenterol. 52 (4): 401–406. doi:10.1007/s00535-017-1314-5. PMID 28188367.
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  6. Inoue, H.; Minami, H.; Kobayashi, Y.; Sato, Y.; Kaga, M.; Suzuki, M.; Satodate, H.; Odaka, N.; Itoh, H. (2010-04-01). "Peroral endoscopic myotomy (POEM) for esophageal achalasia". Endoscopy. 42 (04): 265–271. doi:10.1055/s-0029-1244080. ISSN 0013-726X. PMID 20354937.
  7. Dunst CM, Kurian AA, Swanstrom LL. Endoscopic Myotomy for Achalasia. Advances in Surgery. 2014 Sep:48(1):27-41.
  8. Bechara R, Onimaru M, Ikeda H, Inoue H. Per-oral endoscopic myotomy, 1000 cases later: pearls, pitfalls, and practical considerations. Gastrointest Endosc. 2016 Aug;84(2):330-8
  9. NOSCAR POEM White Paper Committee, Stavropoplous SN, et al. Per-oral endoscopic myotomy white paper summary. Gastrointest Endosc. 2014 Jul;80(1):1-15. NOSCAR POEM White Paper Committee, Stavropoplous SN, et al. Per-oral endoscopic myotomy white paper summary. Gastrointest Endosc. 2014 Jul;80(1):1-15.
  10. Bhayani, NH; Kurlan, AA; Dunst, CM; Sharata, AM; Rieder, E; Swanstrom, LL (Jun 2014). "A comparative study on comprehensive, objective outcomes of laparoscopic Heller myotomy with per-oral endoscopic myotomy (POEM) for achalasia". Ann. Surg. 259 (6): 1098–1103. doi:10.1097/sla.0000000000000268.
  11. Miller HJ, Neupane R, Fayezizadeh M, Majumder A, Marks JM. POEM is a cost-effective procedure: cost-utility analysis of endoscopic and surgical treatment of the options in the management of achalasia. Surg Endosc. 2017 Apr;31(4):1636-1642.
  12. Lundberg PW, Thomas A, DuCoin CR. Cost analysis of laparoscopic Heller myotomy to peroral endoscopic myotomy (POEM). Presented at the meeting of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). Houston, TX; March 23, 2017.
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