Peroral Endoscopic Myotomy (POEM) Procedure

A Comprehensive Overview of Technique, Indications, Outcomes, and Future Directions

Peroral endoscopic myotomy (POEM) is a minimally invasive treatment for achalasia and other conditions that make it hard for you to swallow food. The procedure loosens muscles in your esophagus so food can move to your stomach. It takes about 10 days to two weeks to recover from a POEM procedure.

Introduction

Peroral Endoscopic Myotomy, commonly referred to as POEM, is a revolutionary minimally invasive endoscopic technique developed for the treatment of esophageal motility disorders, primarily achalasia. Since its introduction in 2008 by Dr. Haruhiro Inoue in Japan, POEM has transformed the therapeutic landscape by offering an incisionless alternative to traditional surgical approaches, providing patients with less postoperative discomfort, shorter hospital stays, and excellent clinical outcomes.

Background and Rationale

Achalasia is a rare disease characterized by the inability of the lower esophageal sphincter (LES) to relax and the absence of normal esophageal peristalsis, leading to symptoms such as progressive dysphagia, regurgitation, and chest pain. Historically, treatment options have been limited to pneumatic dilation, botulinum toxin injection, and surgical Heller myotomy. Each of these has significant limitations, including recurrence, invasiveness, or limited durability of effect.

The advent of POEM has been a game-changer, leveraging advances in natural orifice transluminal endoscopic surgery (NOTES) to perform a myotomy with no external incisions. This approach closely mirrors the principles of Heller myotomy but is accomplished entirely endoscopically, making it particularly appealing for patients seeking a less invasive option with robust results.

Indications for POEM

POEM is indicated primarily for the following conditions:

• Primary Achalasia: All subtypes (Type I, II, III) benefit from POEM, including those refractory to other treatments.
• Spastic Esophageal Motility Disorders: Disorders such as diffuse esophageal spasm and jackhammer esophagus.
• Recurrent Symptoms After Previous Interventions: Patients who have failed prior surgical or endoscopic treatments.
• Other Non-Achalasia Motility Disorders: Disorders like esophagogastric junction outflow obstruction, when appropriate.

Candidates are thoroughly evaluated with high-resolution manometry, endoscopy, and sometimes barium esophagram to confirm diagnosis and suitability for POEM.

Preoperative Preparation

Proper patient selection and preparation are crucial for optimal outcomes. Pre-procedure steps include:

• Diagnostic Workup: High-resolution esophageal manometry, EGD (esophagogastroduodenoscopy), and imaging to confirm diagnosis and rule out malignancy.
• Informed Consent: Detailed discussion of risks, benefits, and alternatives, with specific attention to the potential for postoperative gastroesophageal reflux disease (GERD).
• Bowel and Esophageal Preparation: Patients are usually instructed to fast for 12-24 hours prior to the procedure, sometimes with pre-procedure clear liquids or a liquid diet for 1-2 days to clear the esophagus of retained food.
• Antibiotic Prophylaxis: Broad-spectrum antibiotics are typically administered prior to the procedure to reduce infection risk.

Technical Aspects of the POEM Procedure

The POEM procedure consists of several key steps, typically performed under general anesthesia in a dedicated endoscopy suite or operating room:

1. Mucosal Entry (Mucosotomy)

A small (~1.5-2 cm) longitudinal incision is made in the mucosal layer of the esophagus approximately 10-15 cm above the gastroesophageal junction (GEJ), usually on the anterior or posterior wall.

2. Creation of the Submucosal Tunnel

A submucosal tunnel is carefully dissected down through the esophageal wall, extending past the GEJ into the proximal stomach (2-3 cm below the GEJ). Saline mixed with dye is injected to expand the submucosal space for safe dissection.

3. Myotomy

Once the tunnel is created, a selective myotomy of the circular muscle fibers of the esophagus and LES is performed, sparing the longitudinal muscle layer when possible. The length and extent of myotomy are tailored to the patient’s condition, with longer myotomies performed for spastic disorders.

4. Closure of Mucosal Entry

After completing the myotomy, the mucosal incision is closed using endoscopic clips or suturing devices to ensure a watertight seal and prevent leakage or infection.

5. Postoperative Protocol

Patients are monitored postoperatively for signs of complications such as infection, bleeding, or perforation. A water-soluble contrast study may be performed on postoperative day one to check for leaks before initiating oral intake. Most patients are discharged within 1-3 days if stable.

Advantages of POEM

POEM offers several distinct advantages over traditional therapies:

• Minimally Invasive: No external incisions, less postoperative pain, and faster recovery.
• Effective for All Achalasia Types: Especially beneficial for type III (spastic) achalasia, which is less responsive to other therapies.
• Precise Tailoring: The length and location of the myotomy can be precisely tailored to the patient’s needs.
• Durable Results: High long-term efficacy with symptom relief comparable or superior to surgical Heller myotomy.
• Repeatable: Can be performed in patients with failed previous interventions.

Potential Risks and Complications

While POEM is generally safe, as with any procedure, there are risks, including:

• Gastroesophageal Reflux Disease (GERD): Occurs in up to 40-50% of patients post-POEM; managed with lifestyle, medication, or, rarely, additional surgery.
• Bleeding: Rare, usually controlled endoscopically.
• Perforation and Infection: Specified protocol and closure techniques lower this risk, but early detection and management are important.
• Pneumoperitoneum or Pneumomediastinum: Air dissection can lead to accumulation of air in the abdominal or chest cavity, generally self-limited.
• Rare Events: Such as aspiration, strictures, or mucosal injury.

Clinical Outcomes and Efficacy

A growing body of evidence demonstrates that POEM achieves excellent results:

• Symptom Relief: Multiple studies report short- and long-term improvement in dysphagia in 90-95% of patients.
• Durability: Symptom relief is sustained over many years, with low rates of re-intervention.
• Quality of Life: Significant improvement in patient-reported quality of life and satisfaction.
• Comparative Outcomes: POEM demonstrates outcomes comparable to or better than Heller myotomy, especially for spastic motility disorders.

POEM vs. Other Treatment Modalities

POEM is compared favorably to alternatives such as:

• Pneumatic Dilation: Non-surgical, but higher recurrence and need for repeated procedures.
• Botulinum Toxin Injection: Minimally invasive, but effects are short-lived and usually reserved for non-surgical candidates.
• Surgical Heller Myotomy: Traditionally the gold standard, but more invasive, with longer recovery and potential for surgical complications.

POEM provides a less invasive, equally effective, and highly adaptable option, particularly for complex cases.

Post-Procedure Care and Follow-Up

After POEM, a standardized follow-up protocol is essential:

• Diet Advancement: Gradual reintroduction from clear liquids to solids over days to weeks, based on patient tolerance.
• Monitoring for GERD: Routine assessment for reflux symptoms and possible pH monitoring or endoscopy as needed.
• Ongoing Evaluation: Regular clinic visits for symptom assessment, manometry, and imaging, especially in the first year.

Latest Advances and Research

Ongoing research in the field of POEM includes:

• Long-Term Data Collection: Continued tracking of outcomes, adverse events, and patient selection criteria.
• Modifications of Technique: Hybrid POEM, different tunneling approaches (e.g., posterior vs. anterior), and advances in closure devices.
• Expanding Indications: Use in pediatric populations and for non-achalasia disorders.
• Adjunctive Therapies: Combining POEM with anti-reflux procedures, such as endoscopic fundoplication, to mitigate GERD risk.

Patient Experience and Perspective

For patients, POEM represents a significant advancement in esophageal therapy. Most describe marked improvement in swallowing within days to weeks, minimal discomfort, and satisfaction with the lack of external scars. Education and expectation management regarding the risk of reflux and the need for medications or lifestyle changes are important components of the patient journey.

Nursing Care of Patients Undergoing Peroral Endoscopic Myotomy (POEM)

Effective nursing care plays an essential role in the holistic management of patients before, during, and after POEM. The nurse’s expertise ensures patient safety, optimizes recovery, and enhances overall experiences with this advanced endoscopic procedure.

Pre-Procedure Care

• Patient Education: Nurses provide detailed explanations about POEM, including its purpose, expected outcomes, and possible risks. Education should also address fasting protocols, medication management (such as withholding anticoagulants as directed), and what to expect during hospital admission.
• Assessment: Baseline assessments include reviewing the patient’s history of dysphagia, regurgitation, weight loss, and previous interventions. Pre-procedure vital signs and lab results are verified to ensure suitability for anesthesia and endoscopy.
• Anxiety Reduction: Addressing emotional concerns through reassurance, clear communication, and answering questions is vital for reducing preoperative stress.

Intra-Procedure Support

• Patient Monitoring: During POEM, nurses monitor vital signs, provide airway support as needed, and collaborate with the endoscopy team to ensure equipment readiness and sterile conditions.
• Safety and Comfort: Immediate response to changes in patient status, such as hypotension or hypoxia, is critical. Nurses are vigilant for signs of adverse reactions to anesthesia or procedural complications.

Post-Procedure Care

• Close Monitoring: Nurses observe for early complications such as bleeding, chest pain, subcutaneous emphysema, or signs of mediastinitis. Frequent assessment of vital signs, oxygen saturation, and pain levels is essential.
• Diet Advancement: Initial post-procedure management usually involves nothing by mouth (NPO) until esophageal integrity is confirmed, typically with an imaging study. Gradual advancement from clear liquids to soft foods is coordinated based on multidisciplinary recommendations.
• Gastroesophageal Reflux Prevention: Nurses educate patients on lifestyle modifications, positioning (such as elevating the head of the bed), and pharmacologic measures to minimize GERD symptoms, which are common after POEM.
• Patient Education and Discharge Planning: Ongoing instruction includes recognizing warning signs (fever, chest pain, severe dysphagia), medication adherence, follow-up appointments, and the importance of reporting new or worsening symptoms promptly.

Psycho-Social and Emotional Support

• Adjustment Assistance: Nurses support patients in adjusting to changes in eating patterns, social situations, and potential anxiety about recurrence or complications.
• Family Involvement: Engaging family or caregivers in education sessions improves adherence and provides emotional reassurance for both patient and loved ones.

Long-Term Follow-Up

• Symptom Monitoring: Nurses play an important role in follow-up clinics, tracking symptom recurrence, GERD management, and nutritional status over time.
• Coordination of Care: Collaboration with gastroenterologists, dietitians, and primary care providers ensures comprehensive, ongoing support tailored to each patient’s evolving needs.

With skilled nursing care, patients undergoing POEM benefit from smooth perioperative experiences, proactive complication prevention, and the confidence to embrace their improved quality of life.

REFERENCES

1. Campagna RAJ, Cirera A, Holmstrom AL, et.al. Outcomes of 100 Patients More Than 4 Years After POEM for Achalasia.. https://pmc.ncbi.nlm.nih.gov/articles/PMC8260096/Ann Surg. 2021 Jun 1;273(6):1135-1140.
2. Petrov RV, Fajardo RA, Bakhos CT, Abbas AE. Peroral endoscopic myotomy: techniques and outcomes. Shanghai Chest. 2021 Apr;5:14. doi: 10.21037/shc.2020.02.02. PMID: 34013165; PMCID: PMC8130836.
3. Kim JY, Min YW. Peroral Endoscopic Myotomy for Esophageal Motility Disorders. Clin Endosc. 2020 Nov;53(6):638-645. doi: 10.5946/ce.2020.223. Epub 2020 Nov 20. PMID: 33212547; PMCID: PMC7719430.
4. Cho YK, Kim SH. Current Status of Peroral Endoscopic Myotomy. https://pmc.ncbi.nlm.nih.gov/articles/PMC5806926/. Clin Endosc. 2018 Jan;51(1):13-18.
5. Wong I, Law S. Peroral endoscopic myotomy (POEM) for treating esophageal motility disorders. Ann Transl Med. 2017 Apr;5(8):192. doi: 10.21037/atm.2017.04.36. PMID: 28616407; PMCID: PMC5464938.
6. Zhong C, Tan S, Ren Y, Lü M, et.al.Quality of Life Following Peroral Endoscopic Myotomy for Esophageal Achalasia: A Systematic Review and Meta-Analysis. https://pmc.ncbi.nlm.nih.gov/articles/PMC7303313/ Ann Thorac Cardiovasc Surg. 2020 Jun 20;26(3):113-124.
7. Kumbhari V, Khashab MA. Peroral endoscopic myotomy. World J Gastrointest Endosc. 2015 May 16;7(5):496-509. doi: 10.4253/wjge.v7.i5.496. PMID: 25992188; PMCID: PMC4436917.

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