Esophageal Peroral Endoscopic Myotomy

Esophageal Peroral Endoscopic Myotomy

Amy Hosmer, MD

Ryan Law, DO

Prior to 2008, the standard of care for the treatment of achalasia was Heller myotomy. Since that time, the development of per-oral endoscopic myotomy (POEM) has largely supplanted surgical intervention.1 POEM is an endoscopic procedure that allows division of the muscular fibers of the esophagus, including the lower esophageal sphincter to mimic the surgical gold standard. Available data suggest a high rate of procedural and clinical success with a low adverse event rate. Long-term studies will be necessary to determine the durability of this intervention.


  • Advanced or end-stage achalasia

  • Large epiphrenic diverticula in the surgical field

  • Prior irradiation to the mediastinum or esophagus

  • Severe pulmonary disease

  • Coagulopathy, INR >1.5

  • Baseline platelet count <50,000/mm3

  • Prior esophageal endoscopic mucosal resection or other mucosal ablative therapy (i.e., endoscopic submucosal dissection [ESD], photodynamic therapy, radiofrequency ablation)

  • Cirrhosis with portal hypertension


  • 1. Initiate a full liquid diet 3 days prior to the procedure and begin a “clear-liquids-only” diet 24 hours prior to the procedure

  • 2. Patients on anticoagulants and antiplatelet agents should stop or alter their medication after discussion with the prescribing physician

  • 3. Obtain standard preoperative consent by the surgeon/endoscopist and anesthesiologist including risks/benefits/alternatives

  • 4. Place patient in supine position

  • 5. Expose abdomen during procedure to monitor pneumoperitoneum

  • 6. Procedure performed under general anesthesia with endotracheal intubation using a paralytic

  • 7. Give a single dose of prophylactic heparin (10,000 units subcutaneous)

  • 8. Consider a single dose of antibiotic prophylaxis

  • 9. Ensure air insufflation is turned off on the processor


May 29, 2020 | Posted by in GASTROENTEROLOGY | Comments Off on Esophageal Peroral Endoscopic Myotomy

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