Chapter 1 of 7 · Fundamentals
POEM introduction
Introduction to POEM and the case for surgeons learning endoscopic myotomy
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
Video
Update Course 2023 - Updates in Pediatric Achalasia Management
26 min · Published Aug 2023
Video
Laparoscopic Heller Myotomy
3 min · Published Feb 2020
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V119 Use of transoral incisionless fundoplication for recurrent reflux after foregut surgery
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Jeffrey L. Ponsky Master Educator in Endoscopy
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What the experts said
Laparoscopic Heller myotomy is the gold standard for the treatment of achalasia.
In Heller myotomy, the operation fails if the myotomy does not extend 4-5 centimeters down onto the stomach.
A fundoplication (Dor) is added to Heller myotomy based on a Vanderbilt paper, but surgeons know in their hearts it doesn't provide significant benefit.
Dr. Inoue, a thoracic surgeon in Yokohama, performed the first POEM procedure in the world in 2010.
In POEM, the mucosal entry is made 14 centimeters proximal to the EG junction.
During POEM, the longitudinal muscle splits automatically when the circular muscle is divided.
The POEM procedure takes about one hour.
Occasionally during POEM, the mucosa cannot be separated from the submucosa; in these cases (three in seven years for the speaker), the procedure should be stopped, the entry clipped closed, and a Heller myotomy performed instead.
POEM patients have almost a 40% incidence of abnormal reflux.
All POEM patients should be placed on a PPI once daily indefinitely because they can develop strictures without it.
POEM is effective in over 90% of cases.
POEM patients have 35-40% abnormal reflux rates.
Long-term data suggest POEM may be equal to Heller myotomy in every way after three years.
Gastroparesis is caused by diabetes, idiopathic factors, and post-surgical complications including esophagectomy.
POP (peroral pyloromyotomy) involves creating a 4 cm tunnel to the pyloric ring and dividing it, and takes 15 minutes.
The speaker's institution has performed about 400 POP procedures.
In the first 100 POP cases presented at a meeting, three-quarters of patients had normalized gastric emptying studies at three months, all of which were abnormal before the procedure.
POP is an easy procedure that takes 15-20 minutes and is easy to learn, unlike ERCP.
STEER (submucosal tunneling and endoscopic resection) is used to remove esophageal leiomyomas by creating a submucosal tunnel and shelling out the tumor.
The speaker treated a 17-year-old girl with a 7 cm esophageal leiomyoma causing dysphagia using STEER, dividing the tumor in half to remove it through the tunnel.
All esophageal leiomyomas undergo endoscopic ultrasound before STEER.
ENT surgeons are now referring Zenker's diverticulum patients to the speaker because elderly patients with kyphoscoliosis and tight jaws are difficult to manage with general anesthesia and open neck surgery.
Cricopharyngeal myotomy is the basis of treatment for Zenker's diverticulum.
Endoscopic Zenker's treatment takes 15-20 minutes.
For endoscopic Zenker's treatment, patients are kept on clear liquids for a couple of days before the procedure to clear debris from the diverticulum.
During endoscopic Zenker's myotomy, if a hole is made in the mucosa, it does not matter because the mucosal flap will cover it.
The speaker has trained gastroenterologists, thoracic surgeons, and general surgeons to perform intramural surgical procedures.
Thoracic surgeons at the speaker's institution have embraced intramural surgery techniques.
J Pasca at Hopkins originated the idea of creating a submucosal tunnel in the esophagus to avoid gastric leaks during NOTES procedures, and realized the esophageal muscle could be cut endoscopically like a Heller myotomy.
Early European studies of 70 patients showed POEM was effective at one year.
Eric Hungness and Nat Soper reported POEM was effective in an early study of 18 patients.
Lee Swanström's 2014 study of 100 patients showed excellent POEM results but increased reflux compared to Heller myotomy.
Marco Patti's study showed less dysphagia with POEM than with Heller myotomy, but more reflux.
A prospective randomized controlled trial presented in Europe at the end of 2018 compared Heller myotomy with Dor fundoplication versus POEM and found both were effective in controlling dysphagia.
In the 2018 RCT, POEM patients had higher reflux rates than Heller patients at two months, but at three years the reflux rates equalized.