Advertisement

Per-oral Endoscopic Myotomy

  • Amy L. Holmstrom
  • Eric S. HungnessEmail author
Chapter

Abstract

Per-oral endoscopic myotomy is an accepted procedure for the treatment of achalasia. Pre-procedure workup should include upper endoscopy, esophagram, and high-resolution manometry. The procedure is performed in the submucosal space using specialized endoscopic submucosal dissection tools. Submucosal tunneling and selective myotomy of the lower esophageal sphincter circular muscle are key components of the procedure. Common complications include minor bleeding and capno-peritoneum. There are robust short- and moderate-term outcomes data showing procedural safety as well as excellent relief of symptoms compared to laparoscopic Heller myotomy. Emerging long-term literature supports the effectiveness and durability of this procedure.

Keywords

Achalasia High-resolution manometry Per-oral endoscopic myotomy POEM Endoscopic surgery Submucosal dissection Laparoscopic Heller myotomy 

Abbreviations

EGD

esophagogastroduodenoscopy

EGJ

esophagogastric junction

ESD

endoscopic submucosal dissection

GERD

gastroesophageal reflux disease

HRM

high-resolution manometry

POEM

per-oral endoscopic myotomy

TBE

time barium esophagram

Notes

Conflict of Interest

The authors have no conflict of interest to declare.

References

  1. 1.
    Teitelbaum EN, Swanstrom LL. Submucosal surgery: novel interventions in the third space. Lancet Gastroenterol Hepatol. 2018;3(2):134–40.PubMedCrossRefPubMedCentralGoogle Scholar
  2. 2.
    Pasricha PJ, Hawari R, Ahmed I, Chen J, Cotton PB, Hawes RH, et al. Submucosal endoscopic esophageal myotomy: a novel experimental approach for the treatment of achalasia. Endoscopy. 2007;39(9):761–4.PubMedCrossRefPubMedCentralGoogle Scholar
  3. 3.
    Inoue H, Minami H, Kobayashi Y, Sato Y, Kaga M, Suzuki M, et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy. 2010;42(4):265–71.PubMedCrossRefPubMedCentralGoogle Scholar
  4. 4.
    Goldblum JRWR, Orringer MB, Appelman HD. Achalasia. A morphologic study of 42 resected specimens. Am J Surg Pathol. 1994;4(18):327–37.CrossRefGoogle Scholar
  5. 5.
    Sadowski DC, Ackah F, Jiang B, Svenson LW. Achalasia: incidence, prevalence and survival. A population-based study. Neurogastroenterol Motil. 2010;22(9):e256–61.PubMedCrossRefPubMedCentralGoogle Scholar
  6. 6.
    Pandolfino JE, Gawron AJ. Achalasia: a systematic review. JAMA. 2015;313(18):1841–52.PubMedCrossRefPubMedCentralGoogle Scholar
  7. 7.
    Moonen A, Annese V, Belmans A, Bredenoord AJ, Bruley des Varannes S, Costantini M, et al. Long-term results of the European achalasia trial: a multicentre randomised controlled trial comparing pneumatic dilation versus laparoscopic Heller myotomy. Gut. 2016;65(5):732–9.PubMedCrossRefPubMedCentralGoogle Scholar
  8. 8.
    Boeckxstaens GE, Annese V, des Varannes SB, Chaussade S, Costantini M, Cuttitta A, et al. Pneumatic dilation versus laparoscopic Heller’s myotomy for idiopathic achalasia. N Engl J Med. 2011;364(19):1807–16.PubMedCrossRefPubMedCentralGoogle Scholar
  9. 9.
    Patti MG, Pellegrini CA, Horgan S, Arcerito M, Omelanczuk P, Tamburini A, et al. Minimally invasive surgery for achalasia: an 8-year experience with 168 patients. Ann Surg. 1999;230(4):587.PubMedPubMedCentralCrossRefGoogle Scholar
  10. 10.
    Zaninotto G, Costantini M, Molena D, Portale G, Costantino M, Nicoletti L, et al. Minimally invasive surgery for esophageal achalasia. JLaparoendoscAdv Surg Tech. 2001;11(6):351–9.CrossRefGoogle Scholar
  11. 11.
    Eckardt VF. Clinical presentation and complications of achalasia. Gastrointest Endosc Clin N Am. 2001;11(2):281–92.PubMedCrossRefPubMedCentralGoogle Scholar
  12. 12.
    Taft TH, Carlson DA, Triggs J, Craft J, Starkey K, Yadlapati R, et al. Evaluating the reliability and construct validity of the Eckardt symptom score as a measure of achalasia severity. Neurogastroenterol Motil. 2018;30(6):e13287.PubMedPubMedCentralCrossRefGoogle Scholar
  13. 13.
    Bredenoord AJ, Fox M, Kahrilas PJ, Pandolfino JE, Schwizer W, Smout AJPM. Chicago classification criteria of esophageal motility disorders defined in high resolution esophageal pressure topography1. NeurogastroenterolMotil. 2012;24(s1):57–65.CrossRefGoogle Scholar
  14. 14.
    Kahrilas PJ, Bredenoord AJ, Fox M, Gyawali CP, Roman S, Smout AJPM, et al. The Chicago classification of esophageal motility disorders, v3.0. NeurogastroenterolMotil. 2014;27(2):160–74.CrossRefGoogle Scholar
  15. 15.
    Kachala SS, Rice TW, Baker ME, Rajeswaran J, Thota PN, Murthy SC, et al. Value of routine timed barium esophagram follow-up in achalasia after myotomy. J Thorac Cardiovasc Surg. 2018;156:871.PubMedCrossRefGoogle Scholar
  16. 16.
    Stavropoulos SN, Modayil RJ, Friedel D, Savides T. The International Per Oral Endoscopic Myotomy Survey (IPOEMS): a snapshot of the global POEM experience. Surg Endosc. 2013;27(9):3322–38.PubMedCrossRefGoogle Scholar
  17. 17.
    Teitelbaum EN, Soper NJ, Arafat FO, Santos BF, Kahrilas PJ, Pandolfino JE, et al. Analysis of a learning curve and predictors of intraoperative difficulty for peroral esophageal myotomy (POEM). J Gastrointest Surg. 2014;18(1):92–9.PubMedCrossRefGoogle Scholar
  18. 18.
    Kumbhari V, Tieu AH, Onimaru M, El Zein MH, Teitelbaum EN, Ujiki MB, et al. Peroral endoscopic myotomy (POEM) vs laparoscopic Heller myotomy (LHM) for the treatment of type III achalasia in 75 patients: a multicenter comparative study. Endosc Int Open. 2015;3(03):E195–201.PubMedPubMedCentralCrossRefGoogle Scholar
  19. 19.
    Rohof WO, Salvador R, Annese V, Bruley des Varannes S, Chaussade S, Costantini M, et al. Outcomes of treatment for achalasia depend on manometric subtype. Gastroenterology. 2013;144(4):718–25.PubMedCrossRefPubMedCentralGoogle Scholar
  20. 20.
    Hungness ES, Sternbach JM, Teitelbaum EN, Kahrilas PJ, Pandolfino JE, Soper NJ. Per-oral endoscopic myotomy (POEM) after the learning curve: durable long-term results with a low complication rate. Ann Surg. 2016;264(3):508–17.PubMedCrossRefPubMedCentralGoogle Scholar
  21. 21.
    Kurian AA, Dunst CM, Sharata A, Bhayani NH, Reavis KM, Swanström LL. Peroral endoscopic esophageal myotomy: defining the learning curve. Gastrointest Endosc. 2013;77(5):719–25.PubMedCrossRefPubMedCentralGoogle Scholar
  22. 22.
    Swanstrom LL, Rieder E, Dunst CM. A stepwise approach and early clinical experience in peroral endoscopic myotomy for the treatment of achalasia and esophageal motility disorders. J Am Coll Surg. 2011;213(6):751–6.PubMedCrossRefPubMedCentralGoogle Scholar
  23. 23.
    Hungness ES, Jorge JM. Per-oral esophageal myotomy: is it a safe and durable procedure for achalasia? Adv Surg. 2017;51(1):193–205.PubMedCrossRefPubMedCentralGoogle Scholar
  24. 24.
    Hungness ES, Teitelbaum EN, Santos BF, Arafat FO, Pandolfino JE, Kahrilas PJ, et al. Comparison of perioperative outcomes between peroral esophageal myotomy (POEM) and laparoscopic Heller myotomy. J Gastrointest Surg. 2013;17(2):228–35.PubMedCrossRefPubMedCentralGoogle Scholar
  25. 25.
    von Renteln D, Inoue H, Minami H, Werner YB, Pace A, Kersten JF, et al. Peroral endoscopic myotomy for the treatment of achalasia: aprospective single center study. Am J Gastroenterol. 2011;107:411.CrossRefGoogle Scholar
  26. 26.
    Von Renteln D, Fuchs KH, Fockens P, Bauerfeind P, Vassiliou MC, Werner YB, et al. Peroral endoscopic myotomy for the treatment of achalasia: an international prospective multicenter study. Gastroenterology. 2013;145(2):309–11.e3.CrossRefGoogle Scholar
  27. 27.
    El Khoury R, Teitelbaum EN, Sternbach JM, Soper NJ, Harmath CB, Pandolfino JE, et al. Evaluation of the need for routine esophagram after peroral endoscopic myotomy (POEM). Surg Endosc. 2016;30(7):2969–74.PubMedCrossRefPubMedCentralGoogle Scholar
  28. 28.
    Inoue H, Sato H, Ikeda H, Onimaru M, Sato C, Minami H, et al. Per-oral endoscopic myotomy: a series of 500 patients. J Am Coll Surg. 2015;221(2):256–64.PubMedCrossRefPubMedCentralGoogle Scholar
  29. 29.
    Werner YB, Costamagna G, Swanström LL, von Renteln D, Familiari P, Sharata AM, et al. Clinical response to peroral endoscopic myotomy in patients with idiopathic achalasia at a minimum follow-up of 2 years. Gut. 2016;65(6):899–906.PubMedCrossRefPubMedCentralGoogle Scholar
  30. 30.
    Bhayani NH, Kurian AA, Dunst CM, Sharata AM, Rieder E, Swanstrom LL. A comparative study on comprehensive, objective outcomes of laparoscopic Heller myotomy with per-oral endoscopic myotomy (POEM) for achalasia. Ann Surg. 2014;259(6):1098–103.PubMedCrossRefPubMedCentralGoogle Scholar
  31. 31.
    Crespin OM, Liu LWC, Parmar A, Jackson TD, Hamid J, Shlomovitz E, et al. Safety and efficacy of POEM for treatment of achalasia: a systematic review of the literature. Surg Endosc. 2017;31(5):2187–201.PubMedCrossRefPubMedCentralGoogle Scholar
  32. 32.
    Barbieri LA, Hassan C, Rosati R, Romario UF, Correale L, Repici A. Systematic review and meta-analysis: efficacy and safety of POEM for achalasia. United European Gastroenterol J. 2015;3(4):325–34.PubMedPubMedCentralCrossRefGoogle Scholar
  33. 33.
    Marano L, Pallabazzer G, Solito B, Santi S, Pigazzi A, De Luca R, et al. Surgery or peroral esophageal myotomy for achalasia: a systematic review and meta-analysis. Medicine (Baltimore). 2016;95(10):e3001.CrossRefGoogle Scholar
  34. 34.
    Talukdar R, Inoue H, Reddy DN. Efficacy of peroral endoscopic myotomy (POEM) in the treatment of achalasia: a systematic review and meta-analysis. Surg Endosc. 2015;29(11):3030–46.PubMedCrossRefGoogle Scholar
  35. 35.
    Sharata AM, Dunst CM, Pescarus R, Shlomovitz E, Wille AJ, Reavis KM, et al. Peroral endoscopic myotomy (POEM) for esophageal primary motility disorders: analysis of 100 consecutive patients. J Gastrointest Surg. 2015;19(1):161–70; discussion 70.PubMedCrossRefGoogle Scholar
  36. 36.
    Ward MA, Gitelis M, Patel L, Vigneswaran Y, Carbray J, Ujiki MB. Outcomes in patients with over 1-year follow-up after peroral endoscopic myotomy (POEM). Surg Endosc. 2017;31(4):1550–7.PubMedCrossRefGoogle Scholar
  37. 37.
    Teitelbaum EN, Soper NJ, Santos BF, Arafat FO, Pandolfino JE, Kahrilas PJ, et al. Symptomatic and physiologic outcomes one year after peroral esophageal myotomy (POEM) for treatment of achalasia. Surg Endosc. 2014;28(12):3359–65.PubMedCrossRefGoogle Scholar
  38. 38.
    von Renteln D, Inoue H, Minami H, Werner YB, Pace A, Kersten JF, et al. Peroral endoscopic myotomy for the treatment of achalasia: a prospective single center study. Am J Gastroenterol. 2012;107(3):411–7.CrossRefGoogle Scholar
  39. 39.
    Chen X, Li Q-p, Ji G-z, Ge X-x, Zhang X-h, X-y Z, et al. Two-year follow-up for 45 patients with achalasia who underwent peroral endoscopic myotomy. Eur J Cardiothorac Surg. 2015;47(5):890–6.PubMedCrossRefGoogle Scholar
  40. 40.
    Teitelbaum EN, Dunst CM, Reavis KM, Sharata AM, Ward MA, DeMeester SR, et al. Clinical outcomes five years after POEM for treatment of primary esophageal motility disorders. Surg Endosc. 2018;32(1):421–7.PubMedCrossRefPubMedCentralGoogle Scholar
  41. 41.
    Swanstrom LL, Kurian A, Dunst CM, Sharata A, Bhayani N, Rieder E. Long-term outcomes of an endoscopic myotomy for achalasia: the POEM procedure. Ann Surg. 2012;256(4):659–67.PubMedCrossRefPubMedCentralGoogle Scholar
  42. 42.
    Costamagna G, Marchese M, Familiari P, Tringali A, Inoue H, Perri V. Peroral endoscopic myotomy (POEM) for oesophageal achalasia: preliminary results in humans. Dig Liver Dis. 2012;44(10):827–32.PubMedCrossRefPubMedCentralGoogle Scholar
  43. 43.
    Rohof WO, Hirsch DP, Kessing BF, Boeckxstaens GE. Efficacy of treatment for patients with achalasia depends on the distensibility of the esophagogastric junction. Gastroenterology. 2012;143(2):328–35.PubMedCrossRefPubMedCentralGoogle Scholar
  44. 44.
    Akintoye E, Kumar N, Obaitan I, Alayo QA, Thompson CC. Peroral endoscopic myotomy: a meta-analysis. Endoscopy. 2016;48(12):1059–68.PubMedCrossRefPubMedCentralGoogle Scholar
  45. 45.
    Rawlings A, Soper NJ, Oelschlager B, Swanstrom L, Matthews BD, Pellegrini C, et al. Laparoscopic Dor versus Toupet fundoplication following Heller myotomy for achalasia: results of a multicenter, prospective, randomized-controlled trial. Surg Endosc. 2012;26(1):18–26.PubMedCrossRefPubMedCentralGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.Department of SurgeryNorthwestern University Feinberg School of MedicineChicagoUSA

Personalised recommendations