COMMENTARY

Peroral Endoscopic Myotomy for the Treatment of Achalasia

H. Alejandro Rodriguez-Garcia, MD; Monica T. Young, MD; Hope T. Jackson, MD; Brant K. Oelschlager, MD

Disclosures

March 29, 2017

Surgical Technique

The POEM procedure is performed under general anesthesia and endotracheal intubation. The patient is placed in a left lateral decubitus position. Flexible endoscopy is then performed, with any esophageal content aspirated.

In the stomach, the lesser curvature is identified and concentrated methylene blue is injected in the submucosal plane in a site 3 cm distal to the GE junction. An overtube is then placed, and the GE junction is measured. The endoscope is brought 15 cm proximal to the GE junction, and diluted methylene blue is injected in the submucosa. Access to this plane is gained via longitudinal mucosotomy performed with an L-hook.

The submucosal tunnel is then developed using a triangle-tip knife, with sequential injection of dilute methylene blue. Upon reaching the previously marked site on the lesser curvature, the endoscope is brought back 10 cm proximal to the GE junction, and myotomy of the circular fibers is performed in a proximal-to-distal fashion using the L-hook. The myotomy is carried down at least 3 cm distal to the GE junction. The submucosal tunnel and the esophageal lumen are then evaluated for any mucosal tears. The original mucosotomy is closed with endoscopic clips in a distal-to-proximal fashion.

Postoperative care is similar to that for LHM, with the addition that patients who undergo POEM are advised to stay on proton pump inhibitor therapy. A clear liquid diet is started the night of the procedure, which can be advanced to a soft diet in the absence of dysphagia. Follow-up visits are recommended at 2 weeks and 6 months, at which time manometry (Figure 3) and pH studies are performed.

Figure 3. Postoperative manometry showing elimination of the high-pressure zone along the distal esophagus and normal relaxation pressure.

Video: POEM for the treatment of achalasia.

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Conclusion

POEM is a novel technique that offers relief from achalasia symptoms without the need for abdominal incisions. Although early results are promising, long-term follow-up data are needed to assess its efficacy and relative standing in relation to other surgical interventions for achalasia.

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