Per-Oral Endoscopic Myotomy (POEM) for Esophageal Achalasia

Objective. Per-oral endoscopic myotomy (POEM) aims to represent a less invasive alternative to the surgical of achalasia. It was developed after experimental animal studies demonstrated the feasibility of submucosal myotomy.Methods. The POEM procedure was approved by the institutional review board and informed consent was obtained from all patients. Procedures were registered in a prospective university database. Indications include all forms of achalasia except the terminal stage requiring esophagectomy. Since 2008, 420 consecutive patients were treated using this approach.Under general anesthesia with CO2 insufflation, a 0° endoscope with a transparent distal cap (MH-588, Olympus) is inserted. A triangle tip knife (KD-640L, Olympus) is used to dissect the submucosal layer and to divide the circular muscle bundles. A 2 cm longitudinal incision is made on the esophageal mucosa after a submucosal injection of 10 ml saline 13 cm proximal to the gastroesophageal (GE) junction. Spray coagulation mode allows the dissection of the submucosal space down to the stomach, 3 cm below the GE junction. Circular muscle bundles are divided in a 2 o’clock position starting 2 cm from the mucosal incision to 2 cm below the GE junction. The mucosal opening is closed by hemostatic clips.Results. 43 of the patients had sigmoid achalasia. The mean length of the tunnel was 15 cm with a maximum of 26 cm and its width was approximately 1/3 of the esophageal circumference. Pneumoperitoneum occurred in 6%, sometimes requiring needle puncture of the abdomen. One patient had a localized peritonitis controlled by antibiotics and another required a chest tube for a pneumothorax. Symptom score improved dramatically in all cases but a few patients required single balloon dilatation. Symptomatic acid reflux was observed in 23.5% and 4.8% of the patients were treated by proton pump inhibitors.Conclusion. POEM is a novel less invasive treatment of esophageal achalasia with no skin incision. POEM can be applied to any grade achalasia. Short - to middle-term results are excellent.