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.

CONTRAINDICATIONS^a

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

PREPARATION

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

PROCEDURE (ESOPHAGEAL POEM, VIDEO 48.1)

1. Pre-POEM EGD. Prior to POEM, a routine esophagoduodenoscopy (EGD) is performed to clean and lavage contents within the esophagus and stomach. Precise measurements should be obtained to determine the location of the gastroesophageal (GE) junction. The starting point of the circular myotomy and location of the submucosal incision will be based on this measurement. Finally, the esophagus is irrigated with antibiotic solution (i.e., gentamicin 180 mg mixed into 240 mL of sterile saline).
2. Mucosal incision. The submucosal injection/incision will be performed on the anterior esophageal wall ˜2 cm proximal to where the myotomy will begin at the 2 o’clock position (alternative: 5 o’clock position [posterior myotomy]). Once identified, 10 mL of saline + indigo carmine/methylene blue will be injected into the submucosal space using a standard sclerotherapy needle. An ESD knife will then be used to create a 1.5 to 2 cm longitudinal incision using a blended current (i.e., EndoCut mode 2, 50 W) to gain full access to the submucosal space (Fig. 48.1).

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