Per-oral endoscopic myotomy

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Per-oral endoscopic myotomy
Other namesPOEM
Specialty Gastroenterology

The per-oral endoscopic myotomy, or POEM, is a minimally invasive surgical procedure for the treatment of achalasia wherein the inner circular muscle layer of the lower esophageal sphincter is divided through a submucosal tunnel. [1] This enables food and liquids to pass into the stomach, a process that is impaired in achalasia. The tunnel is created, and the myotomy performed, using a flexible endoscope, meaning the entire procedure can be done without external incisions.

Contents

History & development

Achalasia, a disease characterized by impaired esophageal peristalsis and failure of the lower esophageal sphincter to relax, has classically been treated endoscopically by dilation or botulinum toxin injection of the sphincter or surgically by a myotomy in which the muscle fibers are cut through a thoracic or abdominal approach. [1] The principles of an endoscopic surgical myotomy were developed in the 2000s on animal models by Pankaj "Jay" Pasricha at University of Texas Medical Branch. [2] The first endoscopic myotomy was performed on human patients by Haruhiro Inoue in Tokyo in 2008 who then coined the acronym POEM. [3] It has since become increasingly popular internationally as a first-line therapy in patients with achalasia. [4]

Procedure

POEM is a form of natural orifice translumenal endoscopic surgery, or NOTES. Like the traditional surgical myotomy, the procedure is performed under general endotracheal anesthesia. The remainder of the procedure is performed using a flexible endoscope inserted through the mouth, and no cuts are made on the chest or abdomen. Occasionally, an “overtube” is inserted to facilitate repeated removal & insertion of the endoscope. [5] First, a submucosal injection of dyed saline creates a cushion, then a cut is made in the esophageal mucosa using electrocautery roughly 13 centimeters proximal to the lower esophageal sphincter. [6] Then, using hydrostatic dissection and electrocautery, the submucosal tunnel is made. Once the circular fibers of the lower esophageal sphincter are encountered, they are divided using electrocautery all the way down onto the first part of the stomach. This functionally weakens the sphincter, allowing improved passage of food and liquid into the stomach. Finally, the submucosal flap is closed using clips or sutures also placed through the endoscope.

The procedure takes roughly 2 hours but can vary on physician and patient characteristics. Patients usually spend 1–3 days in the hospital before going home, and usually undergo a swallow study prior to resuming oral feeding. [7] Patients may return to work and full activity immediately upon discharge from the hospital. Long-term patient satisfaction is similar following POEM compared to standard laparoscopic Heller myotomy. [8]

Risks & complications

Major complications are rare after POEM and include esophageal perforation and bleeding. [9] Escape of air introduced through the endoscope into the surrounding tissues is a common occurrence and rarely requires additional intervention. [9]

The major long term risk after POEM is new or worsened gastroesophageal reflux disease, which arises in 20-46% of patients. [9] This phenomenon is usually mild and manageable with medication alone, and does not occur at a significantly higher rate than in patients undergoing a traditional surgical therapy. [10] Incomplete myotomy resulting in a persistence of symptoms is also described and requires repeating the procedure.

Cost

As of March, 2017, POEM is classified as an experimental therapy in the United States and is not reimbursed by insurance providers. Recent investigations have demonstrated both equivalency [11] and superiority [12] of POEM compared to laparoscopic Heller myotomy.

Future directions

POEM has been established as a safe and efficacious treatment for achalasia and is becoming increasingly popular as a first line alternative to conventional laparoscopic myotomy. [4] A randomized, controlled trials comparing the two procedures will be published soon as the abstract had been presented during UEGW 2018. This procedure also requires extensive training in advanced endoscopy and a knowledge of the surgical anatomy of the alimentary tract. Currently, many international conferences and post-graduate fellowships in both surgery and gastroenterology specialize in training physicians to perform POEM.

Related Research Articles

<span class="mw-page-title-main">Esophageal achalasia</span> Rare, incurable, progressive motility disorder due to failure of esophogeal motor neurons

Esophageal achalasia, often referred to simply as achalasia, is a failure of smooth muscle fibers to relax, which can cause the lower esophageal sphincter to remain closed. Without a modifier, "achalasia" usually refers to achalasia of the esophagus. Achalasia can happen at various points along the gastrointestinal tract; achalasia of the rectum, for instance, may occur in Hirschsprung's disease. The lower esophageal sphincter is a muscle between the esophagus and stomach that opens when food comes in. It closes to avoid stomach acids from coming back up. A fully understood cause to the disease is unknown, as are factors that increase the risk of its appearance. Suggestions of a genetically transmittable form of achalasia exist, but this is neither fully understood, nor agreed upon.

Heller myotomy is a surgical procedure in which the muscles of the cardia are cut, allowing food and liquids to pass to the stomach. It is used to treat achalasia, a disorder in which the lower esophageal sphincter fails to relax properly, making it difficult for food and liquids to reach the stomach.

<span class="mw-page-title-main">Nissen fundoplication</span> Surgical procedure to treat gastric reflux and hiatal hernia

A Nissen fundoplication, or laparoscopic Nissen fundoplication when performed via laparoscopic surgery, is a surgical procedure to treat gastroesophageal reflux disease (GERD) and hiatal hernia. In GERD, it is usually performed when medical therapy has failed; but, with a Type II (paraesophageal) hiatus hernia, it is the first-line procedure. The Nissen fundoplication is total (360°), but partial fundoplications known as Thal, Belsey, Dor, Lind, and Toupet fundoplications are alternative procedures with somewhat different indications and outcomes.

<span class="mw-page-title-main">Esophagogastroduodenoscopy</span> Diagnostic endoscopic procedure

Esophagogastroduodenoscopy (EGD) or oesophagogastroduodenoscopy (OGD), also called by various other names, is a diagnostic endoscopic procedure that visualizes the upper part of the gastrointestinal tract down to the duodenum. It is considered a minimally invasive procedure since it does not require an incision into one of the major body cavities and does not require any significant recovery after the procedure. However, a sore throat is common.

<span class="mw-page-title-main">Endoscopic retrograde cholangiopancreatography</span> Use of endoscopy and fluoroscopy to treat and diagnose digestive issues.

Endoscopic retrograde cholangiopancreatography (ERCP) is a technique that combines the use of endoscopy and fluoroscopy to diagnose and treat certain problems of the biliary or pancreatic ductal systems. It is primarily performed by highly skilled and specialty trained gastroenterologists. Through the endoscope, the physician can see the inside of the stomach and duodenum, and inject a contrast medium into the ducts in the biliary tree and pancreas so they can be seen on radiographs.

<span class="mw-page-title-main">Endoscopic ultrasound</span>

Endoscopic ultrasound (EUS) or echo-endoscopy is a medical procedure in which endoscopy is combined with ultrasound to obtain images of the internal organs in the chest, abdomen and colon. It can be used to visualize the walls of these organs, or to look at adjacent structures. Combined with Doppler imaging, nearby blood vessels can also be evaluated.

<span class="mw-page-title-main">Double-balloon enteroscopy</span>

Double-balloon enteroscopy, also known as push-and-pull enteroscopy, is an endoscopic technique for visualization of the small bowel. It was developed by Hironori Yamamoto in 2001. It is novel in the field of diagnostic gastroenterology as it is the first endoscopic technique that allows for the entire gastrointestinal tract to be visualized in real time.

Stretta is a minimally invasive endoscopic procedure for the treatment of gastroesophageal reflux disease (GERD) that delivers radiofrequency energy in the form of electromagnetic waves through electrodes at the end of a catheter to the lower esophageal sphincter (LES) and the gastric cardia – the region of the stomach just below the LES. The energy heats the tissue, ultimately causing it to swell and stiffen; the way this works was not understood as of 2015, but it was thought that perhaps the heat causes local inflammation, collagen deposition and muscular thickening of the LES and that it may disrupt the nerves there.

<span class="mw-page-title-main">Nutcracker esophagus</span> Medical condition

Nutcracker esophagus, jackhammer esophagus, or hypercontractile peristalsis, is a disorder of the movement of the esophagus characterized by contractions in the smooth muscle of the esophagus in a normal sequence but at an excessive amplitude or duration. Nutcracker esophagus is one of several motility disorders of the esophagus, including achalasia and diffuse esophageal spasm. It causes difficulty swallowing, or dysphagia, with both solid and liquid foods, and can cause significant chest pain; it may also be asymptomatic. Nutcracker esophagus can affect people of any age but is more common in the sixth and seventh decades of life.

<span class="mw-page-title-main">Self-expandable metallic stent</span>

A self-expandable metallic stent is a metallic tube, or stent that holds open a structure in the gastrointestinal tract to allow the passage of food, chyme, stool, or other secretions related to digestion. Surgeons insert SEMS by endoscopy, inserting a fibre optic camera—either through the mouth or colon—to reach an area of narrowing. As such, it is termed an endoprosthesis. SEMS can also be inserted using fluoroscopy where the surgeon uses an X-ray image to guide insertion, or as an adjunct to endoscopy.

<span class="mw-page-title-main">Endoclip</span>

An endoclip is a metallic mechanical device used in endoscopy in order to close two mucosal surfaces without the need for surgery and suturing. Its function is similar to a suture in gross surgical applications, as it is used to join together two disjointed surfaces, but, can be applied through the channel of an endoscope under direct visualization. Endoclips have found use in treating gastrointestinal bleeding, in preventing bleeding after therapeutic procedures such as polypectomy, and in closing gastrointestinal perforations. Many forms of endoclips exist of different shapes and sizes, including two and three prong devices, which can be administered using single use and reloadable systems, and may or may not open and close to facilitate placement.

Therapeutic endoscopy is the medical term for an endoscopic procedure during which treatment is carried out via the endoscope. This contrasts with diagnostic endoscopy, where the aim of the procedure is purely to visualize a part of the gastrointestinal, respiratory or urinary tract in order to aid diagnosis. In practice, a procedure which starts as a diagnostic endoscopy may become a therapeutic endoscopy depending on the findings, such as in cases of upper gastrointestinal bleeding, or the finding of polyps during colonoscopy.

The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) is a 501c6 non-profit professional organization providing education on gastrointestinal minimally invasive surgery. It describes itself thus: The mission of the Society of American Gastrointestinal and Endoscopic Surgeons is to innovate, educate and collaborate to improve patient care.

Endoscopic mucosal resection is a technique used to remove cancerous or other abnormal lesions found in the digestive tract. It is one method of performing a mucosectomy.

Endoscopic submucosal dissection (ESD) is an advanced surgical procedure using endoscopy to remove gastrointestinal tumors that have not entered the muscle layer. ESD may be done in the esophagus, stomach or colon. Application of endoscopic resection (ER) to gastrointestinal (GI) neoplasms is limited to lesions with no risk of nodal metastasis. Either polypectomy or endoscopic mucosal resection (EMR) is beneficial for patients because of its low level of invasiveness. However, to ensure the curative potential of these treatment modalities, accurate histopathologic assessment of the resected specimens is essential because the depth of invasion and lymphovascular infiltration of the tumor is associated with considerable risk for lymph node metastasis. For accurate assessment of the appropriateness of the therapy, en bloc resection is more desirable than piecemeal resection. For a reliable en bloc resection of GI neoplasms, a new method of ER called endoscopic submucosal dissection (ESD) has been developed.

<span class="mw-page-title-main">Michel Kahaleh</span>

Michel Kahaleh is an American gastroenterologist and an expert in therapeutic endoscopy.

<span class="mw-page-title-main">Biliary endoscopic sphincterotomy</span> Use of endoscopy and fluoroscopy to treat and diagnose digestive issues.

Biliary endoscopic sphincterotomy is a procedure where the sphincter of Oddi and the segment of the common bile duct where it enters the duodenum are cannulated and then cut with a sphincterotome, a device that includes a wire which cuts with an electric current (electrocautery).

Esophagogastric junction outflow obstruction (EGJOO) is an esophageal motility disorder characterized by increased pressure where the esophagus connects to the stomach at the lower esophageal sphincter. EGJOO is diagnosed by esophageal manometry. However, EGJOO has a variety of etiologies; evaluating the cause of obstruction with additional testing, such as upper endoscopy, computed tomography, or endoscopic ultrasound may be necessary. When possible, treatment of EGJOO should be directed at the cause of obstruction. When no cause for obstruction is found, observation alone may be considered if symptoms are minimal. Functional EGJOO with significant or refractor symptoms may be treated with pneumatic dilation, per-oral endoscopic myotomy (POEM), or botulinum toxin injection.

<span class="mw-page-title-main">Jay Pasricha</span>

Pankaj "Jay" Pasricha is a physician and researcher specializing in gastroenterology and neurogastroenterology. He currently serves as the chair of medicine at the Mayo Clinic in Scottsdale, Arizona. Formerly, he served as the director of the Johns Hopkins Center for Neurogastroenterology and was the founder and co-director of the Amos Food, Body and Mind Center, Vice Chair of Medicine for Innovation and Commercialization in the Johns Hopkins School of Medicine, and Professor of Innovation Management at the Carey Business School.

<span class="mw-page-title-main">Haruhiro Inoue</span>

Haruhiro Inoue is a Japanese thoracic surgeon and endoscopist best known for the development of the cap endoscopic mucosal resection technique, and the first per-oral endoscopic myotomy performed in humans. He is a professor at Showa University and Director of the Digestive Disease Centre at Showa University Koto-Toyosu Hospital in Tokyo. He is known for his work in endoscopy and his contribution to the development of endoscopic technologies and procedures.

References

  1. 1 2 Chuah, SK; Chiu, CH; Tai, WC; Lee, JH; Lu, HI; Changchien, CS; Tseng, PH; Wu, KL (7 September 2013). "Current status in the treatment options for esophageal achalasia". World Journal of Gastroenterology. 19 (33): 5421–9. doi: 10.3748/wjg.v19.i33.5421 . PMC   3761094 . PMID   24023484.
  2. ↑ Pasricha, PJ; Hawari, R; Ahmed, I; Chen, J; Cotton, PB; Hawes, RH; Kalloo, AN; Kantsevoy, SV; Gostout, CJ (2007). "Submucosal endoscopic esophageal myotomy: a novel experimental approach for the treatment of achalasia". Endoscopy. 39 (9): 761–764. doi:10.1055/s-2007-966764. PMID   17703382.
  3. ↑ Inoue H, Kudo SE. Per-oral endoscopic myotomy (POEM) for 43 consecutive cases of esophageal achalasia. Nihon Rinsho. 2010 Sep;68(9):1749-52
  4. 1 2 Tuason, J; Inoue, H (Apr 2017). "Current status of achalasia management: a review on diagnosis and treatment". J Gastroenterol. 52 (4): 401–406. doi: 10.1007/s00535-017-1314-5 . PMID   28188367.
  5. ↑ 4
  6. ↑ Inoue, H; Minami, H; Kobayashi, Y; Sato, Y; Kaga, M; Suzuki, M; Satodate, H; Odaka, N; Itoh, H; Kudo, S (April 2010). "Peroral endoscopic myotomy (POEM) for esophageal achalasia". Endoscopy. 42 (4): 265–71. doi:10.1055/s-0029-1244080. PMID   20354937.
  7. ↑ Dunst, CM; Kurian, AA; Swanstrom, LL (2014). "Endoscopic myotomy for achalasia". Advances in Surgery. 48: 27–41. doi:10.1016/j.yasu.2014.05.015. PMID   25293605.
  8. ↑ Bechara, R; Onimaru, M; Ikeda, H; Inoue, H (August 2016). "Per-oral endoscopic myotomy, 1000 cases later: pearls, pitfalls, and practical considerations". Gastrointestinal Endoscopy. 84 (2): 330–8. doi: 10.1016/j.gie.2016.03.1469 . PMID   27020899.
  9. 1 2 3 NOSCAR POEM White Paper, Committee.; Stavropoulos, SN; Desilets, DJ; Fuchs, KH; Gostout, CJ; Haber, G; Inoue, H; Kochman, ML; Modayil, R; Savides, T; Scott, DJ; Swanstrom, LL; Vassiliou, MC (July 2014). "Per-oral endoscopic myotomy white paper summary". Gastrointestinal Endoscopy. 80 (1): 1–15. doi: 10.1016/j.gie.2014.04.014 . PMID   24950639.
  10. ↑ Bhayani, NH; Kurlan, AA; Dunst, CM; Sharata, AM; Rieder, E; Swanstrom, LL (Jun 2014). "A comparative study on comprehensive, objective outcomes of laparoscopic Heller myotomy with per-oral endoscopic myotomy (POEM) for achalasia". Ann. Surg. 259 (6): 1098–1103. doi:10.1097/sla.0000000000000268. PMID   24169175. S2CID   21973555.
  11. ↑ Miller, HJ; Neupane, R; Fayezizadeh, M; Majumder, A; Marks, JM (April 2017). "POEM is a cost-effective procedure: cost-utility analysis of endoscopic and surgical treatment options in the management of achalasia". Surgical Endoscopy. 31 (4): 1636–1642. doi:10.1007/s00464-016-5151-z. PMID   27534662. S2CID   28457632.
  12. ↑ Lundberg PW, Thomas A, DuCoin CR. Cost analysis of laparoscopic Heller myotomy to peroral endoscopic myotomy (POEM). Presented at the meeting of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). Houston, TX; March 23, 2017.
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