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Surgical Management of Achalasia: Peroral Endoscopic Myotomy

  • Joel Sternbach
  • Eric HungnessEmail author
Chapter

Abstract

A novel procedure, combining the decreased invasiveness of endoscopic access with the reliability of a surgical myotomy, peroral endoscopic myotomy (POEM), represents a potential paradigm shift in the management of idiopathic achalasia and other esophageal motor disorders. Comprehensive preoperative evaluation by a multidisciplinary team of gastroenterologists and surgeons is essential to confirming candidacy for POEM and appropriately counseling patients on expected outcomes and postoperative outcomes, including the lack of long-term outcome data. The key steps of the procedure are detailed, including initial EGD, safe access to the submucosal space, creation of a submucosal tunnel extending at least 3 cm onto the gastric cardia, selective myotomy of the inner circular muscle fibers, and closure of the mucosotomy. Frequently encountered complications include bleeding, inadvertent mucosotomy, full-thickness perforation, and development of capnothorax and/or capnoperitoneum.

Keywords

POEM Achalasia NOTES Myotomy Dysphagia 

Abbreviations

DES

Diffuse esophageal spasm

DI

Distensibility index

EGD

Esophagogastroduodenoscopy

EGJ

Esophagogastric junction

EMR

Endoscopic mucosal resection

EPT

Esophageal pressure topography

ES

Eckardt score

ESD

Endoscopic submucosal dissection

FLIP

Functional lumen imaging probe

GERD

Gastroesophageal reflux disease

HRIM

High-resolution impedance manometry

HRM

High-resolution manometry

IDQ

Impaction-dysphagia questionnaire, GERDQ

LES

Lower esophageal sphincter

NOTES

Natural orifice transluminal endoscopic surgery

POEM

Peroral endoscopic myotomy

TBE

Timed barium esophagram

VSI

Visceral sensitivity index

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Copyright information

© SAGES 2019

Authors and Affiliations

  1. 1.Department of SurgeryNorthwestern Memorial HospitalChicagoUSA

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