Per-oral oesophageal myotomy (POEM)
Per-oral oesophageal myotomy (POEM) is a natural orifice endoscopic surgery that has been gaining increasing use as an alternative to traditional oesophageal myotomies (e.g. Heller myotomy and Nissen fundoplication).
With this technique, the endoscopist insufflates the oesophagus with CO2 then creates a 2 cm opening approximately 12 cm above the squamocolumnar junction and then creates a submucosal path to the lower oesophageal sphincter and usually into the cardia of the stomach. He or she then incises the sphincter/ circular muscle (myotomy), and at the end of the procedure withdraws the scope, closing the mucosal opening with staples. The whole procedure is performed beneath the mucosa under general anesthesia.
Most patients receive a fluoroscopic oesophageal swallow study either immediately after the procedure or soon after the procedure.
The most common scope approach is anteriorly in the oesophagus, so the RPO position is often best to profile the clips 2.
Water-soluble contrast (e.g. Gastrografin) is usually used first in case there is an occult perforation.
- clips at the surface of the oesophagus, indicating the entrance to the submucosal tunnel (usually fall off with time)
- small amount of pneumoperitoneum, pneumomediastinum, intramural gastric pneumatosis, retroperitoneal gas, as well as intramural dissection and contrast leak are common findings post procedure mostly leakage from CO2 instillation through the scope during the procedure; these usually resolve spontaneously and no further intervention is required
Treatment and prognosis
- distal sphincter dilatation less than 5 mm post POEM is considered poor response
- contrast leak outside the oesophagus (perforation)
- a large amount of pneumoperitoneum (concerning for perforation)
- 1. Inoue H, Tianle KM, Ikeda H et-al. Peroral endoscopic myotomy for esophageal achalasia: technique, indication, and outcomes. Thorac Surg Clin. 2011;21 (4): 519-25. doi:10.1016/j.thorsurg.2011.08.005 - Pubmed citation
- 2. Harmath C, Horowitz J, Berggruen S et-al. Fluoroscopic findings post-peroral esophageal myotomy. Abdom Imaging. 2015;40 (2): 237-45. doi:10.1007/s00261-014-0209-7 - Pubmed citation
- 3. Levy JL, Levine MS, Rubesin SE, Falk GW, Metz DC, Dempsey DT, Ginsberg GG. Findings of Esophagography for 25 Patients After Peroral Endoscopic Myotomy for Achalasia. AJR. American journal of roentgenology. 207 (6): 1185-1193. doi:10.2214/AJR.16.16365 - Pubmed