At a Glance:
1. What is peroral endoscopic myotomy (POEM)?
2. What are the indications of POEM?
3. Can every person with achalasia undergo POEM, what are the contraindications?
4. How long does POEM surgery take?
5. What to expect before POEM?
6. How is the POEM procedure done?
8. Is POEM safe, are there any risks?
9. What is the success rate of POEM?
11. What are the benefits of POEM?
POEM is an endoscopic procedure that is performed for the treatment of certain disorders of swallowing. It is performed using a high-definition upper endoscope in the endoscopy unit of a hospital.
An endoscope is a flexible tubular instrument that can be passed through the mouth or rectum to visualize and treat medical conditions of the inner surfaces of the structures like the food pipe i.e esophagus, stomach, intestine, and colon.
POEM is generally indicated for treating the following disease:
Achalasia: It is a medical condition that affects the muscles of the esophagus. The lower esophageal sphincter (LES), a muscularvalve present between the esophagus and the stomach fails to relax during swallowing in this condition. Consequently, the food doesn’t move forward into the stomach from the esophagus. The common symptoms of achalasia are:
Achalasia can be corrected by cutting the muscles of the esophageal sphincter surgically and the procedure is known as myotomy. Peroral endoscopic myotomy (POEM) is a newer technique for the surgical management of achalasia with an endoscopic approach.
Diffuse esophageal spasm: Esophageal disorders of muscle spasm that are unresponsive to medical therapies
Nutcracker esophagus also known as hypertensive peristalsis is a muscle spasm disorder which needs surgical correction.
Even though POEM is a safe and effective procedure, it may not be a suitable option in certain cases. Persons with any of the following conditions are generally not recommended to undergo POEM for achalasia:
POEM is a minimally invasive procedure that can be done in two to three hours approximately. A person may be expected to stay in the hospital for a period of two to three days during which he/she is monitored by the treating gastroenterologist and administered intravenous medications like antibiotics.
To ensure optimized patient outcomes, accurate diagnosis of achalasia or a spastic esophageal disorder is essential. Perioperative evaluation of the person is done by the doctors on the basis of the following investigation and information:
Clinical history and physical examination: A standardized, validated symptom assessment methodology called the Eckardt score or grading system is followed by doctors to diagnose and determine the severity of achalasia. The final score of the person is the sum of the individual ratings for each symptom/sign.
The Eckardt Score for Achalasia Severity:
| Signs/Symptoms | Score for each symptom/sign | |||
|---|---|---|---|---|
| 0 | 1 | 2 | 3 | |
| Recent Weight loss(kg) | None | < 5 | 5 – 10 | > 10 |
| Dysphagia | None | Occasional | Daily | Each meal |
| Chest pain | None | Occasional | Daily | Several times per day |
| Regurgitation | None | Occasional | Daily | Each meal |
Tests: Some of the undermentioned tests may be advised by the treating gastroenterologist to confirm the diagnosis of achalasia before the procedure is undertaken.
Esophageal manometry: A high-resolution esophageal manometry test is done on an outpatient basis for the detection of problems pertaining to movement and pressure within the esophagus. Such problems may be the underlying cause of symptoms. The strength and muscle coordination of the esophagus during swallowing is measured by manometry.
Contrast esophagram: It is a diagnostic radiology examination for the upper gastrointestinal (GI) tract that includes parts like the esophagus, throat, and back of the mouth. This test is done using X-rays or an X-ray video (fluoroscopy). Also known as barium swallow, a contrast esophagram helps the doctors in diagnosing structural or functional issues of the upper GI tract like achalasia, ulcers, dysphagia, hiatal hernia, tumors or cancers, etc.
In some persons, barium may cause constipation. Hence it is recommended to drink plenty of fluids and high fiber food to facilitate the movement of the barium through the gastrointestinal tract. It is usually advised to not eat or drink anything after midnight of the night before the exam.
Esophagogastroduodenoscopy (EGD): In this diagnostic procedure a small flexible tube fitted with a camera, known as the endoscope, is introduced through the mouth or the nose and advanced to the esophagus and duodenum through the upper GI tract. Depending on the condition of the person, the procedure may be performed under moderate sedation or with topical anesthesia. General anesthesia is generally reserved for persons who are unlikely to tolerate the procedure while awake. This procedure helps in ruling out other conditions like cancer of the esophagus.
pH studies: Prolonged esophageal pH monitoring is not done in every case. However, in certain cases, it may be advised to rule out other problems like gastroesophageal reflux disease.
Before the procedure is undertaken, the doctor would advise specific preparatory instructions depending on the person’s medical status. Some of the commonly advised preparatory instructions are as follows:
During POEM procedure:
In case anesthesia is administered, some time is required to allow for recovery in the endoscopy unit. The person may be admitted to the hospital for monitoring and administration of any prescribed intravenous medications like antibiotics for a day or two. The doctor may advise a person to be nil by mouth i.e. not to eat anything on the night of the procedure.
A barium swallow is usually advised the next day morning. Depending on the outcome of the test, the person may be allowed to drink liquids and then advance to a soft diet the following day.
We obtain an esophagram on the day after the procedure to exclude an esophageal leak, after which a soft diet is allowed. Patients are advised to remain on a soft diet for 10 to 14 days before starting a regular diet.
Once discharged from the hospital, a person may be placed on prescription medications like antibiotics or antacids for a few days.
It is highly recommended to follow up with the gastroenterologist in the OPD as advised at the time of discharge. Another barium swallow study after a few months may be advised to ascertain that the esophagus empties well.
When performed by an experienced gastroenterologist, POEM is a safe procedure. It is usually associated with a low rate of postoperative adverse events. As per the available scientific literature, the incidence of procedure-related adverse events in POEM is extremely low which is approximately 8%. Most of the complications that occur after POEM are relatively mild and easy to be managed expectantly, medically, or endoscopically. However, as with any surgery, there may be general and specific individual risks. Some of the commonly encountered risks are:
Side effects of anesthesia that may include:
Specific risks associated with the procedure include:
Studies have shown that POEM is a safe and effective procedure. The response of the procedure in individuals with achalasia cardia is durable. The outcomes of POEM are not influenced by a history of any prior treatment. Available literature shows that patients in the range of 4 to 77 years with a mean age of 40 have undergone the procedure with a 97% completion rate. Clinical success rates at 1, 2 and 3 years are 94 %, 91 %, and 90 %, respectively.
Endoscopic pyloromyotomy (G-POEM): This procedure is usually advised for the treatment of gastroparesis. In this procedure, instead of the lower esophageal sphincter in POEM, myotomy of the pylorus is done. The surgical procedure for G-POEM is similar to that of POEM.
Gastroparesis is a syndrome that results in delayed gastric emptying i.e. the inability of the stomach to empty itself of food normally. The hallmark of this condition is the absence of mechanical obstruction. Some of the symptoms which the condition usually presents are:
In most of the cases of gastroparesis the etiology or the causative factors may be unknown (or idiopathic), diabetes, or postsurgical.
For a person undergoing the procedure, one of the main advantages of POEM for the treatment of swallowing disorders is that there is no requirement of incisions in the chest or abdomen. Another advantage is minimal or sometimes no hospital stay after the procedure. Endoscopic procedures usually result in negligible complications and faster recovery.
Some of the advantages of POEM experienced by doctors include:
The choice of facility for availing treatment of conditions like achalasia eventually depends on the person and his/her family and medical needs. However, an informed decision must be taken after considering the availability of the required expertise and infrastructure in the preferred facility.
Advanced procedures like POEM should be performed in high-volume centers of excellence with a one-stop availability of advanced diagnostic techniques like high-resolution manometry, fully equipped endoscopic suite, technique trained and experienced gastroenterologists and support staff.
Persons with swallowing disorders often have special nutritional and lifestyle needs. Nutrition plays a large role in the management of the symptoms of an esophagus or swallowing disorder. Led by gastroenterologists trained and experienced in procedures like POEM, the Center for Gastroenterology at Yashoda hospital, Hyderabad offers comprehensive services comprising of specialized teams for nutrition therapy, intestinal rehabilitation, and nutrition support for persons suffering from swallowing disorders.
Surgical myotomy considered to be the treatment of choice for persons with achalasia and certain disorders of swallowing. However, with advancements in surgical techniques, there are lesser invasive options now available for individuals to consider. Procedures like balloon dilatation or injection of Botox provide sustainable relief in certain cases but they also have a disadvantage of short-term results and the need for repeat interventions. Scar tissue formed due to these interventions can complicate a future laparoscopic repair as the chances of perforation increase. This makes complete myotomy difficult.
Peroral endoscopic myotomy (POEM), a newer option that can overcome these constraints is now available in specialized centers. POEM utilizes the advanced endoscopic technique of submucosal tunneling and is a totally endoscopic procedure.
Advantages of the endoscopic myotomy are shorter recovery time, a lower rate of complications and better treatment outcomes.
About Author –
Dr. Parthasarathy G, Consultant Surgical Gastroenterologist, Yashoda Hospitals – Hyderabad
MS, MCh
Specialized in general, laparoscopic and minimal access surgeries and procedures for problems of gastroenterology such as cancers, piles, fistula, hernia, gallstones, liver and pancreatic problems.
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