Per-oral endoscopic myotomy for achalasia: An American perspective

Abstract

Achalasia is an uncommon esophageal motility disorder characterized by the selective loss of enteric neurons leading to absence of peristalsis and impaired relaxation of the lower esophageal sphincter. Per-oral endoscopic myotomy (POEM) is a novel modality for the treatment of achalasia performed by gastroenterologists and surgeons. It represents a natural orifice transluminal endoscopic surgery (NOTES) approach to Heller myotomy. POEM has the minimal invasiveness of an endoscopic procedure that can duplicate results of the surgical Heller myotomy. POEM is conceptually similar to a surgical myotomy without the inherent external incisions and post-operative care associated with surgery. Initial high success and low complications rates promise a great future for this technique. In fact, POEM has been successfully performed on patients with end-stage achalasia as an initial treatment reserving esophagectomy for those without good response. The volume of POEMs performed worldwide has grown exponentially. In fact, surgeons who have performed Heller myotomy have embraced POEM as the preferred intervention for achalasia. However, the niche of POEM remains to be defined and long term results are awaited. We describe our experience with POEM having performed the first POEM outside of Japan in 2009, the evolution of our technique, and give our perspective on its future.

Keywords: Per-oral endoscopic myotomy, Achalasia, Heller myotomy, Natural orifice transluminal endoscopic surgery, Per-oral endoscopic myotomy, Minimally invasive surgery

Core tip: Per-oral endoscopic myotomy (POEM) is a minimally invasive endoscopic procedure that duplicates results of the surgical Heller myotomy. This innovative technique has been performed by both gastroenterologists and surgeons. POEM has been shown to be safe and effective in patients with classic achalasia and modest follow-up data. POEM has also been successfully applied in patients with hypertensive esophageal motor disorders as well as end-stage achalasia. It is recommended that prior to performing POEM, operators should have experience in endoscopic submucosal dissection or substantial training in animal models.