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.
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 by Pankaj "Jay" Pasricha at University of Texas Medical Branch.[2] The first endoscopic myotomy was performed on human patients by Haruhiro Inoue in Tokyo 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]
ProcedureEdit
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 proximal to 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 laparoscopicHeller myotomy.[8]
Risks & complicationsEdit
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.
CostEdit
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 directionsEdit
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.
ReferencesEdit
^ abChuah, SK; Chiu, CH; Tai, WC; Lee, JH; Lu, HI; Changchien, CS; Tseng, PH; Wu, KL (7 September 2013). "Current status in the treatment options for esophageal achalasia". World Journal of Gastroenterology. 19 (33): 5421–9. doi:10.3748/wjg.v19.i33.5421. PMC3761094. PMID 24023484.
^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 (9): 761–764. doi:10.1055/s-2007-966764. PMID 17703382.
^Inoue H, Kudo SE. Per-oral endoscopic myotomy (POEM) for 43 consecutive cases of esophageal achalasia. Nihon Rinsho. 2010 Sep;68(9):1749-52
^ abTuason, 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.
^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. PMID 24169175. S2CID 21973555.
^Miller, HJ; Neupane, R; Fayezizadeh, M; Majumder, A; Marks, JM (April 2017). "POEM is a cost-effective procedure: cost-utility analysis of endoscopic and surgical treatment options in the management of achalasia". Surgical Endoscopy. 31 (4): 1636–1642. doi:10.1007/s00464-016-5151-z. PMID 27534662. S2CID 28457632.
^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.
August 25, 2023
oral, endoscopic, myotomy, oral, endoscopic, myotomy, poem, minimally, invasive, surgical, procedure, treatment, achalasia, wherein, inner, circular, muscle, layer, lower, esophageal, sphincter, divided, through, submucosal, tunnel, this, enables, food, liquid. 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 Per oral endoscopic myotomyOther namesPOEMSpecialtyGastroenterology edit on Wikidata Contents 1 History amp development 2 Procedure 3 Risks amp complications 4 Cost 5 Future directions 6 ReferencesHistory amp development EditAchalasia 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 by Pankaj Jay Pasricha at University of Texas Medical Branch 2 The first endoscopic myotomy was performed on human patients by Haruhiro Inoue in Tokyo 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 EditPOEM 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 amp 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 proximal to 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 amp complications EditMajor 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 EditAs 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 EditPOEM 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 References Edit a b Chuah SK Chiu CH Tai WC Lee JH Lu HI Changchien CS Tseng PH Wu KL 7 September 2013 Current status in the treatment options for esophageal achalasia World Journal of Gastroenterology 19 33 5421 9 doi 10 3748 wjg v19 i33 5421 PMC 3761094 PMID 24023484 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 9 761 764 doi 10 1055 s 2007 966764 PMID 17703382 Inoue H Kudo SE Per oral endoscopic myotomy POEM for 43 consecutive cases of esophageal achalasia Nihon Rinsho 2010 Sep 68 9 1749 52 a b 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 4 Inoue H Minami H Kobayashi Y Sato Y Kaga M Suzuki M Satodate H Odaka N Itoh H Kudo S April 2010 Peroral endoscopic myotomy POEM for esophageal achalasia Endoscopy 42 4 265 71 doi 10 1055 s 0029 1244080 PMID 20354937 Dunst CM Kurian AA Swanstrom LL 2014 Endoscopic myotomy for achalasia Advances in Surgery 48 27 41 doi 10 1016 j yasu 2014 05 015 PMID 25293605 Bechara R Onimaru M Ikeda H Inoue H August 2016 Per oral endoscopic myotomy 1000 cases later pearls pitfalls and practical considerations Gastrointestinal Endoscopy 84 2 330 8 doi 10 1016 j gie 2016 03 1469 PMID 27020899 a b c NOSCAR POEM White Paper Committee Stavropoulos SN Desilets DJ Fuchs KH Gostout CJ Haber G Inoue H Kochman ML Modayil R Savides T Scott DJ Swanstrom LL Vassiliou MC July 2014 Per oral endoscopic myotomy white paper summary Gastrointestinal Endoscopy 80 1 1 15 doi 10 1016 j gie 2014 04 014 PMID 24950639 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 PMID 24169175 S2CID 21973555 Miller HJ Neupane R Fayezizadeh M Majumder A Marks JM April 2017 POEM is a cost effective procedure cost utility analysis of endoscopic and surgical treatment options in the management of achalasia Surgical Endoscopy 31 4 1636 1642 doi 10 1007 s00464 016 5151 z PMID 27534662 S2CID 28457632 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 Retrieved from https en wikipedia org w index php title Per oral endoscopic myotomy amp oldid 1170320590, wikipedia, wiki, book, books, library,
