Published online May 16, 2015. doi: 10.4253/wjge.v7.i5.496
Peer-review started: October 6, 2014
First decision: October 28, 2014
Revised: November 15, 2014
Accepted: January 18, 2015
Article in press: January 20, 2015
Published online: May 16, 2015
Peroral endoscopic myotomy (POEM) incorporates concepts of natural orifice translumenal endoscopic surgery and achieves endoscopic myotomy by utilizing a submucosal tunnel as an operating space. Although intended for the palliation of symptoms of achalasia, there is mounting data to suggest it is also efficacious in the management of spastic esophageal disorders. The technique requires an understanding of the pathophysiology of esophageal motility disorders as well as knowledge of surgical anatomy of the foregut. POEM achieves short term response in 82% to 100% of patients with minimal risk of adverse events. In addition, it appears to be effective and safe even at the extremes of age and regardless of prior therapy undertaken. Although infrequent, the ability of the endoscopist to manage an intraprocedural adverse event is critical as failure to do so could result in significant morbidity. The major late adverse event is gastroesophageal reflux which appears to occur in 20% to 46% of patients. Research is being conducted to clarify the optimal technique for POEM and a personalized approach by measuring intraprocedural esophagogastric junction distensibility appears promising. In addition to esophageal disorders, POEM is being studied in the management of gastroparesis (gastric pyloromyotomy) with initial reports demonstrating technical feasibility. Although POEM represents a paradigm shift the management of esophageal motility disorders, the results of prospective randomized controlled trials with long-term follow up are eagerly awaited.
Core tip: Peroral endoscopic myotomy (POEM) is a minimally invasive, scarless approach to Heller myotomy for the palliation of symptoms of achalasia and spastic esophageal disorders. Current data demonstrates short-term success with minimal adverse events. POEM is no longer considered experimental with approximately 5000 procedures performed worldwide. In the future, a personalized approach to POEM will be undertaken with tailoring of the length of gastric myotomy based on intraprocedural physiological measurements. This will allow sufficient reduction in pressure at the lower esophageal sphincter for adequate relief of symptoms but also minimize gastroesophageal reflux.