POEM and the management of achalasia

Abstract

Achalasia is a rare oesophageal motility disorder predominantly causing dysphagia and regurgitation of food and fluids. Diagnosis is made typically after a combination of tests including endoscopy, barium swallow and oesophageal manometry. The advent of high-resolution manometry has led to the Chicago Classification which divided achalasia into three types. This improved the understanding of presentation, prognosis and might also help tailor therapy. Botulinum toxin has been shown to have good, but short-term efficacy. The predominant treatments include pneumatic balloon dilatation and laparoscopic Heller's myotomy, both of which have similar and durable outcomes, although the success of both reduces with time. Per-oral endoscopic myotomy (POEM) has been shown to be as effective, safe and durable as earlier treatments for achalasia; however, randomised controlled trials are lacking. Indications for POEM are expanding to other hypercontractile motility disorders of the oesophagus.

Superior clinical outcomes of peroral endoscopic myotomy compared with balloon dilation in all achalasia subtypes

“…Achalasia is a progressive disorder that results in an impaired LES . The various modalities for the management of achalasia include pharmacological treatment, endoscopic pneumatic BD, botulinum injection, Heller's myotomy, and, more recently, POEM . BD uses air pressure to intraluminally dilate and disrupt the circular muscle fibers of the LES.…”

“…12 The various modalities for the management of achalasia include pharmacological treatment, endoscopic pneumatic BD, botulinum injection, Heller's myotomy, and, more recently, POEM. 13 BD uses air pressure to intraluminally dilate and disrupt the circular muscle fibers of the LES. For many years, repeated endoscopic BD has been the treatment of choice, leading to therapeutic success rates of 86% and 85% at 2 and 5 years, respectively.…”

Peroral Endoscopic Myotomy

“…Gastroesophageal reflux disease is a commonly known adverse event of invasive treatment for achalasia (Nabi et al, 2018). The most common complication of POEM is acid reflux, occurring in 20%–46% of patients (Banks & Sweis, 2017). Therefore, the nurse should anticipate orders for continuation of proton pump inhibitors (PPIs).…”

Robotic Heller-Dor myotomy: 10-year monocentric experience compared with POEM

“…Moreover, is well recognized that POEM is a complex procedure reserved to experienced endoscopists and that should be performed in high volume centers only in order to guarantee the best outcome for patients. Endoscopists must be an expert in esophageal pathology and must be familiar with main operative procedures such as submucosal dissection as well as being able to face intraprocedural complications [9,21,24,33]. Training process should start from watching the procedure performed by more experienced operators familiarizing with required equipment.…”

“…Recent advantages in endoscopic procedures, which are even less invasive and painful than surgical interventions performed laparoscopically, have introduced a novel technique of Per-Oral Endoscopic Miotomy (POEM) among the therapeutic options for achalasia. It is an advanced endoscopic procedure which consists in creating a submucosal tunnel from the middle third of the esophagus to the proximal stomach, followed by a myotomy extended from 2 cm below initial mucosal incision towards the cardia [8,9]. At the beginning POEM was criticized for the absence of any anti-reflux valve system confection, which may result in post-procedural gastro-esophageal reflux occurrence.…”