Early Experience With Peroral Endoscopic Myotomy (POEM)

OBJECTIVE: Peroral Endoscopic Myotomy (POEM) is an emerging new technique for treatment of achalasia. Here we describe the results of our early clinical experience with POEM.

DESCRIPTION: Five patients (3 female, 2 male; age 30-73, mean 53) with manometry proven achalasia were enrolled in our IRB approved study and underwent POEM between June and October 2011. In all cases, under general anesthesia, a mucosal incision was made endoscopically in the midesophagus (20-28cm, mean 24cm) with submucosal tunneling past the gastroesophageal (GE) junction. The circular muscle fibers were then divided using a triangle tip blade with monopolar electrocautery down to the gastric cardia (10-12cm in length, mean 11cm). The distance between the mucosal entry site and the start of the myotomy was 6 to 10cm (mean 8). The gastroscope was able to easily pass through the GE junction at the end of all procedures. The mucosal entry was closed with endoscopic clips. All patients had esophagrams performed on the first postoperative day to assess for leak.

RESULTS: All five patients tolerated the procedure well with postoperative esophagram negative for leak. Four of the five patients reported complete resolution of their symptoms postoperatively. The fifth patient was found to have delayed emptying of contrast from the distal esophagus on the postoperative esophagram, though this was much improved from the preoperative study. The patient reported only 20% improvement of symptoms; however upper endoscopy two weeks postoperatively found the GE junction to be widely patent. The patient subsequently required placement of a gastrostomy tube for nutritional support, with plans for possible later dilatation. Three of five patients developed pneumoperitoneum intraoperatively, requiring Veress needle placement for decompression. No patients required conversion to Heller Myotomy.

CONCLUSION: In our short series, POEM appears to be a safe and effective technique for the treatment of achalasia. POEM is specifically focused to the affected pathology in achalasia, namely the circular muscle layer. This directed approach may lead to increased effectiveness and decreased complications in comparison to the other treatment modalities. However, longer-term follow up and continued experience are critical to determine its ultimate role in achalasia management.

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