Clin Endosc.  2018 Jan;51(1):13-18. 10.5946/ce.2017.165.

Current Status of Peroral Endoscopic Myotomy

• Cho YK
• Kim SH

• KMID: 2403627
• DOI: http://doi.org/10.5946/ce.2017.165

Abstract

Peroral endoscopic myotomy (POEM) has been established as an optional treatment for achalasia. POEM is an endoluminal procedure that involves dissection of esophageal muscle fibers followed by submucosal tunneling. Inoue first attempted to use POEM for the treatment of achalasia in humans. Expanded indications of POEM include classic indications such as type I, type II, type III achalasia, failed prior treatments, including Botulinum toxin injection, endoscopic balloon dilation, laparoscopic Heller myotomy, and hypertensive motor disorders such as diffuse esophageal spasm, jackhammer esophagus. Contraindications include prior radiation therapy to the esophagus and prior extensive esophageal mucosal resection/ablation involving the POEM field. Most of the complications are minor and self-limited and can be managed conservatively. As POEM emerged as the main treatment for achalasia, various adaptations to tunnel endoscopic surgery have been attempted. Tunnel endoscopic surgery includes POEM, peroral endoscopic tumor resection, gastric peroral endoscopic pyloromyotomy. POEM has been widely accepted as a treatment for all types of achalasia, even for specific cases such as achalasia with failed prior treatments, and hypertensive motor disorders.

Keyword

Peroral endoscopic myotomy; Achalasia; Natural orifice transluminal endoscopic surgery; Heller myotomy

MeSH Terms

Botulinum Toxins
Esophageal Achalasia
Esophageal Spasm, Diffuse
Esophagus
Humans
Motor Disorders
Natural Orifice Endoscopic Surgery
Botulinum Toxins

Figure

• 

  Fig. 1. Peroral endoscopic myotomy stages. (A) Submucosal injection. (B) Mucosal incision at the 2 o’clock postion. (C) Submucosal tunneling. (D) Myotomy. (E) Closure with hemoclips.

Reference

1. Francis DL, Katzka DA. Achalasia: update on the disease and its treatment. Gastroenterology. 2010; 139:369–374.

2. Richter JE. The diagnosis and misdiagnosis of achalasia: it does not have to be so difficult. Clin Gastroenterol Hepatol. 2011; 9:1010–1011.

3. Eckardt VF, Aignherr C, Bernhard G. Predictors of outcome in patients with achalasia treated by pneumatic dilation. Gastroenterology. 1992; 103:1732–1738.

4. Verlaan T, Rohof WO, Bredenoord AJ, Eberl S, Rösch T, Fockens P. Effect of peroral endoscopic myotomy on esophagogastric junction physiology in patients with achalasia. Gastrointest Endosc. 2013; 78:39–44.

5. Campos GM, Vittinghoff E, Rabl C, et al. Endoscopic and surgical treatments for achalasia: a systematic review and meta-analysis. Ann Surg. 2009; 249:45–57.

6. Inoue H, Minami H, Kobayashi Y, et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy. 2010; 42:265–271.

7. Pasricha PJ, Hawari R, Ahmed I, et al. Submucosal endoscopic esophageal myotomy: a novel experimental approach for the treatment of achalasia. Endoscopy. 2007; 39:761–764.

8. Richter JE. Oesophageal motility disorders. Lancet. 2001; 358:823–828.

9. Hart P, Francis D. Barium esophagram remains a highly sensitive screening examination for the diagnosis of achalasia: 3. Am J Gastroenterol. 2009; 104(Suppl 3):S1.

10. Kahrilas PJ, Kishk SM, Helm JF, Dodds WJ, Harig JM, Hogan WJ. Comparison of pseudoachalasia and achalasia. Am J Med. 1987; 82:439–446.

11. Bredenoord AJ, Fox M, Kahrilas PJ, Pandolfino JE, Schwizer W, Smout AJ. Chicago classification criteria of esophageal motility disorders defined in high resolution esophageal pressure topography. Neurogastroenterol Motil. 2012; 24 Suppl 1:57–65.

12. Teitelbaum EN, Hungness ES. Peroral endoscopic myotomy periprocedural evaluation: predicting and measuring outcomes. Tech Gastrointest Endosc. 2013; 15:135–139.

13. von Renteln D, Inoue H, Minami H, et al. Peroral endoscopic myotomy for the treatment of achalasia: a prospective single center study. Am J Gastroenterol. 2012; 107:411–417.

14. Sharata A, Kurian AA, Dunst CM, Bhayani NH, Reavis KM, Swanström LL. Peroral endoscopic myotomy (POEM) is safe and effective in the setting of prior endoscopic intervention. J Gastrointest Surg. 2013; 17:1188–1192.

15. Zhou PH, Li QL, Yao LQ, et al. Peroral endoscopic remyotomy for failed Heller myotomy: a prospective single-center study. Endoscopy. 2013; 45:161–166.

16. Khashab MA, Messallam AA, Onimaru M, et al. International multicenter experience with peroral endoscopic myotomy for the treatment of spastic esophageal disorders refractory to medical therapy (with video). Gastrointest Endosc. 2015; 81:1170–1177.

17. Shiwaku H, Inoue H, Beppu R, et al. Successful treatment of diffuse esophageal spasm by peroral endoscopic myotomy. Gastrointest Endosc. 2013; 77:149–150.

18. Ko WJ, Lee BM, Park WY, et al. Jackhammer esophagus treated by a peroral endoscopic myotomy. Korean J Gastroenterol. 2014; 64:370–374.

19. Stavropoulos SN, Modayil RJ, Friedel D, Savides T. The international per oral endoscopic myotomy survey (IPOEMS): a snapshot of the global POEM experience. Surg Endosc. 2013; 27:3322–3338.

20. Ling TS, Guo HM, Yang T, Peng CY, Zou XP, Shi RH. Effectiveness of peroral endoscopic myotomy in the treatment of achalasia: a pilot trial in Chinese Han population with a minimum of one-year follow-up. J Dig Dis. 2014; 15:352–358.

21. Wang J, Tan N, Xiao Y, et al. Safety and efficacy of the modified peroral endoscopic myotomy with shorter myotomy for achalasia patients: a prospective study. Dis Esophagus. 2015; 28:720–727.

22. Liu XJ, Tan YY, Yang RQ, et al. The outcomes and quality of life of patients with achalasia after peroral endoscopic myotomy in the short-term. Ann Thorac Cardiovasc Surg. 2015; 21:507–512.

23. Ramchandani M, Nageshwar Reddy D, Darisetty S, et al. Peroral endoscopic myotomy for achalasia cardia: treatment analysis and follow up of over 200 consecutive patients at a single center. Dig Endosc. 2016; 28:19–26.

24. Costamagna G, Marchese M, Familiari P, Tringali A, Inoue H, Perri V. Peroral endoscopic myotomy (POEM) for oesophageal achalasia: preliminary results in humans. Dig Liver Dis. 2012; 44:827–832.

25. Inoue H, Sato H, Ikeda H, et al. Per-oral endoscopic myotomy: a series of 500 patients. J Am Coll Surg. 2015; 221:256–264.

26. Shiwaku H, Inoue H, Yamashita K, et al. Peroral endoscopic myotomy for esophageal achalasia: outcomes of the first over 100 patients with shortterm follow-up. Surg Endosc. 2016; 30:4817–4826.

27. Lee BH, Shim KY, Hong SJ, et al. Peroral endoscopic myotomy for treatment of achalasia: initial results of a Korean study. Clin Endosc. 2013; 46:161–167.

28. Teitelbaum EN, Soper NJ, Santos BF, et al. Symptomatic and physiologic outcomes one year after peroral esophageal myotomy (POEM) for treatment of achalasia. Surg Endosc. 2014; 28:3359–3365.

29. Sharata AM, Dunst CM, Pescarus R, et al. Peroral endoscopic myotomy (POEM) for esophageal primary motility disorders: analysis of 100 consecutive patients. J Gastrointest Surg. 2015; 19:161–170. discussion 170.

30. Khashab MA, El Zein M, Kumbhari V, et al. Comprehensive analysis of efficacy and safety of peroral endoscopic myotomy performed by a gastroenterologist in the endoscopy unit: a single-center experience. Gastrointest Endosc. 2016; 83:117–125.

31. Talukdar R, Inoue H, Nageshwar Reddy D. Efficacy of peroral endoscopic myotomy (POEM) in the treatment of achalasia: a systematic review and meta-analysis. Surg Endosc. 2015; 29:3030–3046.

32. Barbieri LA, Hassan C, Rosati R, Romario UF, Correale L, Repici A. Systematic review and meta-analysis: efficacy and safety of POEM for achalasia. United European Gastroenterol J. 2015; 3:325–334.

33. Patel K, Abbassi-Ghadi N, Markar S, Kumar S, Jethwa P, Zaninotto G. Peroral endoscopic myotomy for the treatment of esophageal achalasia: systematic review and pooled analysis. Dis Esophagus. 2016; 29:807–819.

34. Akintoye E, Kumar N, Obaitan I, Alayo QA, Thompson CC. Peroral endoscopic myotomy: a meta-analysis. Endoscopy. 2016; 48:1059–1068.

35. Ujiki MB, Yetasook AK, Zapf M, Linn JG, Carbray JM, Denham W. Peroral endoscopic myotomy: a short-term comparison with the standard laparoscopic approach. Surgery. 2013; 154:893–897. discussion 897-900.

36. Teitelbaum EN, Rajeswaran S, Zhang R, et al. Peroral esophageal myotomy (POEM) and laparoscopic Heller myotomy produce a similar shortterm anatomic and functional effect. Surgery. 2013; 154:885–891. discussion 891-892.

37. Kumagai K, Tsai JA, Thorell A, Lundell L, Håkanson B. Per-oral endoscopic myotomy for achalasia. Are results comparable to laparoscopic Heller myotomy? Scand J Gastroenterol. 2015; 50:505–512.

38. Ngamruengphong S, Inoue H, Chiu PW, et al. Long-term outcomes of per-oral endoscopic myotomy in patients with achalasia with a minimum follow-up of 2 years: an international multicenter study. Gastrointest Endosc. 2017; 85:927–933.e2.

39. Kim WH, Cho JY, Ko WJ, et al. Comparison of the outcomes of peroral endoscopic myotomy for achalasia according to manometric subtype. Gut Liver. 2017; 11:642–647.

40. Khan MA, Kumbhari V, Ngamruengphong S, et al. Is POEM the answer for management of spastic esophageal disorders? A systematic review and meta-analysis. Dig Dis Sci. 2017; 62:35–44.

41. Minami H, Inoue H, Haji A, et al. Per-oral endoscopic myotomy: emerging indications and evolving techniques. Dig Endosc. 2015; 27:175–181.

42. Li H, Linghu E, Wang X. Fibrin sealant for closure of mucosal penetration at the cardia during peroral endoscopic myotomy (POEM). Endoscopy. 2012; 44 Suppl 2 UCTN:E215–E216.

43. Kurian AA, Bhayani NH, Reavis K, Dunst C, Swanström L. Endoscopic suture repair of full-thickness esophagotomy during per-oral esophageal myotomy for achalasia. Surg Endosc. 2013; 27:3910.

44. Modayil R, Friedel D, Stavropoulos SN. Endoscopic suture repair of a large mucosal perforation during peroral endoscopic myotomy for treatment of achalasia. Gastrointest Endosc. 2014; 80:1169–1170.

45. Bechara R, Onimaru M, Ikeda H, Inoue H. Per-oral endoscopic myotomy, 1000 cases later: pearls, pitfalls, and practical considerations. Gastrointest Endosc. 2016; 84:330–338.

46. Minami H, Isomoto H, Yamaguchi N, et al. Peroral endoscopic myotomy for esophageal achalasia: clinical impact of 28 cases. Dig Endosc. 2014; 26:43–51.

47. von Renteln D, Fuchs KH, Fockens P, et al. Peroral endoscopic myotomy for the treatment of achalasia: an international prospective multicenter study. Gastroenterology. 2013; 145:309–311.e3.

48. Eleftheriadis N, Inoue H, Ikeda H, Onimaru M, Maselli R, Santi G. Submucosal tunnel endoscopy: peroral endoscopic myotomy and peroral endoscopic tumor resection. World J Gastrointest Endosc. 2016; 8:86–103.

49. Li QL, Zhou PH. Perspective on peroral endoscopic myotomy for achalasia: Zhongshan experience. Gut Liver. 2015; 9:152–158.

50. Onimaru M, Inoue H, Ikeda H, et al. Greater curvature myotomy is a safe and effective modified technique in per-oral endoscopic myotomy (with videos). Gastrointest Endosc. 2015; 81:1370–1377.

51. Onimaru M, Inoue H, Ikeda H, et al. Peroral endoscopic myotomy is a viable option for failed surgical esophagocardiomyotomy instead of redo surgical Heller myotomy: a single center prospective study. J Am Coll Surg. 2013; 217:598–605.

52. Eleftheriadis N, Protopapas A, Katsogridakis J, Hatzitolios AI. Successful peroral endoscopic myotomy for radical treatment of sigmoid-type esophageal achalasia by Greek gastroenterologists. Ann Gastroenterol. 2014; 27:430–431.

53. Li QL, Chen WF, Zhou PH, et al. Peroral endoscopic myotomy for the treatment of achalasia: a clinical comparative study of endoscopic full-thickness and circular muscle myotomy. J Am Coll Surg. 2013; 217:442–451.

54. Li C, Gong A, Zhang J, et al. Clinical outcomes and safety of partial full-thickness myotomy versus circular muscle myotomy in peroral endoscopic myotomy for achalasia patients. Gastroenterol Res Pract. 2017; 2017:2676513.

55. Wang XH, Tan YY, Zhu HY, Li CJ, Liu DL. Full-thickness myotomy is associated with higher rate of postoperative gastroesophageal reflux disease. World J Gastroenterol. 2016; 22:9419–9426.

56. Inoue H, Ikeda H, Hosoya T, et al. Submucosal endoscopic tumor resection for subepithelial tumors in the esophagus and cardia. Endoscopy. 2012; 44:225–230.

57. Xu MD, Cai MY, Zhou PH, et al. Submucosal tunneling endoscopic resection: a new technique for treating upper GI submucosal tumors originating from the muscularis propria layer (with videos). Gastrointest Endosc. 2012; 75:195–199.

58. Wang XY, Xu MD, Yao LQ, et al. Submucosal tunneling endoscopic resection for submucosal tumors of the esophagogastric junction originating from the muscularis propria layer: a feasibility study (with videos). Surg Endosc. 2014; 28:1971–1977.

59. Ye LP, Zhang Y, Mao XL, Zhu LH, Zhou X, Chen JY. Submucosal tunneling endoscopic resection for small upper gastrointestinal subepithelial tumors originating from the muscularis propria layer. Surg Endosc. 2014; 28:524–530.

60. Khashab MA, Stein E, Clarke JO, et al. Gastric peroral endoscopic myotomy for refractory gastroparesis: first human endoscopic pyloromyotomy (with video). Gastrointest Endosc. 2013; 78:764–768.

61. Shlomovitz E, Pescarus R, Cassera MA, et al. Early human experience with per-oral endoscopic pyloromyotomy (POP). Surg Endosc. 2015; 29:543–551.

62. Chaves DM, de Moura EG, Mestieri LH, Artifon EL, Sakai P. Endoscopic pyloromyotomy via a gastric submucosal tunnel dissection for the treatment of gastroparesis after surgical vagal lesion. Gastrointest Endosc. 2014; 80:164.

63. Jung Y, Lee J, Gromski MA, et al. Assessment of the length of myotomy in peroral endoscopic pyloromyotomy (G-POEM) using a submucosal tunnel technique (video). Surg Endosc. 2015; 29:2377–2384.