POEM in the Treatment of Esophageal Disorders
- 250 Downloads
Purpose of the review
Peroral endoscopic myotomy (POEM) is a novel minimally invasive technique that has emerged as the preferred option for the treatment of achalasia and spastic esophageal disorders (SED) at many centers around the world. In this article, we review and summarize the recent literature on POEM in patients with achalasia and SED. The current article is largely focused on the new developments and findings, extended applications, and long-term outcomes of POEM in patients with achalasia and SED.
POEM is a safe and effective therapy for patients with achalasia and SED. POEM is comparable to Heller myotomy (HM) in terms of safety, efficacy, and complications, including gastroesophageal reflux disease (GERD). Outcomes of POEM are excellent even in patients who had prior failed therapies for achalasia, including failed HM and prior POEM. Recent data also suggest the efficacy and safety of POEM in both pediatric and geriatric patients. GERD after POEM is common, and the majority of patients are asymptomatic. The management, goals of therapy, and long-term outcomes of GERD after POEM are unclear. Objective testing for all patients is recommended.
POEM is a validated treatment for all patients with achalasia and SED. Candidates should be carefully selected and appropriately counseled on expected outcomes and the need for long-term surveillance.
KeywordsPOEM Peroral endoscopic myotomy Achalasia Esophageal motility disorders Heller myotomy Outcomes
Compliance with Ethical Standards
Conflict of Interest
Nasim Parsa declares no conflict of interest.
Mouen A. Khashab is a consultant for Boston Scientific and Olympus America. He also serves on the medical advisory board of Boston Scientific and Olympus America.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
References and Recommended Reading
Papers of particular interest, published recently, have been highlighted as: • Of importance ••Of major importance
- 4.Winter H, Shukla R, Elshaer M, Riaz A. Current management of achalasia—a review. Br J Med Pr. 2015;8(2):810.Google Scholar
- 7.Stavropoulos SN, Desilets DJ, Fuchs K-H, Gostout CJ, Haber G, Inoue H, et al. Per-oral endoscopic myotomy white paper summary. Gastrointest Endosc [Internet]. 2014;80(1):1–15. Available from: http://linkinghub.elsevier.com/retrieve/pii/S0016510714013492. https://doi.org/10.1016/j.gie.2014.04.014.CrossRefGoogle Scholar
- 8.Boeckxstaens G, Annese V, Des Varannes S, Chaussade S, Costantini M, Cuttitta A, et al. European achalasia trial I (2011) pneumatic dilation versus laparoscopic Heller’s myotomy for idiopathic achalasia. N Engl J Med. 2011;364(19):1807–16. https://doi.org/10.1056/NEJMoa1010502.PubMedCrossRefGoogle Scholar
- 11.Fumagalli U, Rosati R, De Pascale S, Porta M, Carlani E, Pestalozza A, et al. Repeated surgical or endoscopic myotomy for recurrent dysphagia in patients after previous myotomy for achalasia. J Gastrointest Surg. 2016;20(3):494–9. https://doi.org/10.1007/s11605-015-3031-9.PubMedCrossRefGoogle Scholar
- 12.Onimaru M, Inoue H, Ikeda H, Yoshida A, Santi E, Sato H, et al. Peroral endoscopic myotomy is a viable option for failed surgical esophagocardiomyotomy instead of redo surgical Heller myotomy. J Am Coll Surg. 2013;217(4):598–605. https://doi.org/10.1016/j.jamcollsurg.2013.05.025.PubMedCrossRefGoogle Scholar
- 15.•• Ngamruengphong S, Inoue H, Ujiki M, Patel LY, Bapaye A, Desai PN, et al. Efficacy and safety of peroral endoscopic myotomy for treatment of achalasia after failed Heller myotomy. Clin Gastroenterol Hepatol. 2017;15(10):1531–1537. Largest comparative study on POEM between patients with and without prior HM that reported similar technical success, clinical success and AE rates between the two groups, but lower clinical success rates in the HM group. https://doi.org/10.1016/j.cgh.2017.01.031.PubMedCrossRefGoogle Scholar
- 19.Chan SM, Wu JCY, Teoh AYB, Yip HC, Ng EKW, Lau JYW, et al. Comparison of early outcomes and quality of life after laparoscopic Heller’s cardiomyotomy to peroral endoscopic myotomy for treatment of achalasia. Dig Endosc. 2016;28(1):27–32. https://doi.org/10.1111/den.12507.PubMedCrossRefGoogle Scholar
- 22.•• Tyberg A, Seewald S, Sharaiha R, Martinez G, Desai A, Kumta N, et al. A multicenter international registry of redo per oral endoscopic myotomy (POEM) after failed POEM. Gastrointest Endosc. 2017;85(6):1208–1211. Largest study on patients who underwent redo POEM, reporting a clinical success rate of 85% after a mean follow up of 3 months. https://doi.org/10.1016/j.gie.2016.10.015.PubMedCrossRefGoogle Scholar
- 27.••Chen Y-I, Inoue H, Ujiki M, Draganov P., Colavita P, Mion F, et al. An international multicenter study evaluating the clinical efficacy and safety of per-oral endoscopic myotomy in octogenarians. Gastrointest Endosc. 16AD. Largest study on POEM in geriatric population that reported a clinical success rate of 90.8% after a median follow up of 256 days.Google Scholar
- 32.Miao S, Wu J, Lu J, Wang Y, Tang Z, Zhou Y, et al. Peroral endoscopic myotomy in children with achalasia: a relatively long-term single-center study. J Pediatr Gastroenterol Nutr. 2017;Google Scholar
- 33.•Caldaro T, Familiari P, Francesca E, Gigante G, Marchese M, Chiara A, et al. Treatment of esophageal achalasia in children: today and tomorrow. J Pediatr Surg. 2015;(50):726–30. Comparative study between POEM vs HM in pediatric patients that reported a shorter operative time, faster time to feeding and more rapid discharge in the POEM group.Google Scholar
- 34.• Tan Y, Zhu H, Li C, Chu Y, Huo J, Liu D. Comparison of peroral endoscopic myotomy and endoscopic balloon dilation for primary treatment of pediatric achalasia. J Pediatr Surg. 2016;51(10):1613–1618. Comparative study between POEM and PBD in pediatric patients that reported a better intermediate and long term clinical success rates in the POEM group. https://doi.org/10.1016/j.jpedsurg.2016.06.008.PubMedCrossRefGoogle Scholar
- 41.Teitelbaum E, Soper N, Pandolfino J, Kahrilas P, Hirano I, Boris L, et al. Esophagogastric junction distensibility measurements during Heller myotomy and POEM for achalasia predict postoperative symptomatic outcomes. Surg Endosc. 2015;29(3):522–8. https://doi.org/10.1007/s00464-014-3733-1.PubMedCrossRefGoogle Scholar
- 42.Bhayani N, Kurian A, Dunst CM, Sharata A, Reider E, Swanstrom LL. A comparative study on comprehensive, objective outcomes of laparoscopic Heller myotomy with peroral endoscopic myotomy (POEM) for achalasia. Ann Surg. 2014;259(6):1098–103. https://doi.org/10.1097/SLA.0000000000000268.PubMedCrossRefGoogle Scholar
- 44.•• Awaiz A, Yunus RM, Khan S, Memon B, Memon MA. Systematic review and meta-analysis of perioperative outcomes of peroral endoscopic myotomy (POEM) and laparoscopic Heller myotomy (LHM) for achalasia. Surg Laparosc Endosc Percutan Tech. 2017;27(3):123–131. Systematic review and meta-analysis comparing POEM vs HM in 483 patients. This study reported a similar risk of GERD, length of stay in the hospital, AE rate and postoperative pain score between the two groups, but higher clinical failure rate in the HM group. https://doi.org/10.1097/SLE.0000000000000402.PubMedCrossRefGoogle Scholar
- 47.Jia G, Shan H, Zhang D, Wu L, Zhu L. Peroral endoscopic myotomy for treatment of achalasia of cardia: analysis of 7 cases. Chinese J Gastroenterol. 2014;19:232–4.Google Scholar
- 48.Lu B. Curative effect and security analysis of peroral endoscopic myotomy in treatment of 20 cases of achalasia. J Gastroenterol Hepatol. 2015;28:487.Google Scholar
- 53.Yaqi Z, Enqiang L, Huikai L, Zhichu Q, Xiangdong W, Hong D, et al. Comparison of peroral endoscopic myotomy with transverse entry incision versus longitudinal entry incision for achalasia. J SouthernMedical Univ. 2013;33:1399–402.Google Scholar
- 54.Li Q, Chen W, Zhou P, Yao LQ, Xu MD, Hu JW, 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(3):442–51. https://doi.org/10.1016/j.jamcollsurg.2013.04.033.PubMedCrossRefGoogle Scholar
- 57.von Rahden B, Filser J, Reimer S, Inoue H, Germer C. Peroral endoscopic myotomy for treatment of achalasia. Literature review and own initial experience. Der Chir Zeitschrift fur alle Gebiete der Oper Medizen. 2014;85:420–32.Google Scholar
- 59.Ramchandani M, Reddy DN, Darisetty S, Kotla R, Chavan R, Kalpala R, 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(1):19–26. https://doi.org/10.1111/den.12495.PubMedCrossRefGoogle Scholar
- 68.Khashab MA, El Zein M, Kumbhari V, Ngamruengphong SBS, Abdelgalil AMA, Saxena P, 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(1):117–25. https://doi.org/10.1016/j.gie.2015.06.013.PubMedCrossRefGoogle Scholar
- 69.Orenstein S, Raigani S, Wu Y, Pauli E, Phillips M, Ponsky J, et al. Peroral endoscopic myotomy (POEM) leads to similar results in patients with and without prior endoscopic or surgical therapy. Surg Endosc. 2014;28:272.Google Scholar
- 79.Ren Z, Zhong Y, Author PZ, Xu M, Cai M, Li L, et al. Perioperative management and treatment for complications during and after peroral endoscopic myotomy (POEM) for esophageal achalasia (EA) (data from 119 cases). Surg Endosc. 2012;26(11):3267–72. https://doi.org/10.1007/s00464-012-2336-y.PubMedCrossRefGoogle Scholar
- 81.Khashab M, Messallam A, Onimaru M, Teitelbaum E, Ujiki M, Gitelis 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(5):1170–7. https://doi.org/10.1016/j.gie.2014.10.011.PubMedCrossRefGoogle Scholar
- 93.•• Haito-Chavez Y, Inoue H, Beard KW, Draganov PV, Ujiki M, Rahden BHA, et al. Comprehensive analysis of adverse events associated with per oral endoscopic myotomy in 1826 patients: an international multicenter study. Am J Gastroenterol. 2017;112(8):1267–76. https://doi.org/10.1038/ajg.2017.139. Largest study on POEM AEs in 1826 patients. The overall reported prevalence of AE was 7.5%, but only 0.5% were severe.PubMedCrossRefGoogle Scholar
- 95.Werner YB, Costamagna G, Swanström LL, Von Renteln D, Familiari P, Sharata AM, et al. Clinical response to peroral endoscopic myotomy in patients with idiopathic achalasia at a minimum follow-up of 2 years. Endoscopy. 2016;65:899–906.Google Scholar
- 96.• Ngamruengphong S, Inoue H, Chiu PW-Y, Yip HC, Bapaye A, Ujiki M, 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(5):927–933.e2. A large multicenter study that included 205 patients who underwent POEM with reported clinical success rate of 91% after a mean follow up of 31 months. https://doi.org/10.1016/j.gie.2016.09.017.PubMedCrossRefGoogle Scholar
- 97.Guo H, Yang H, Zhang X, Wang L, Lv Y, Zou X, et al. Long-term outcomes of peroral endoscopic myotomy for patients with achalasia: a retrospective single-center study. Dis Esophagus [Internet]. 2017;30(5):1–6. Available from: https://academic.oup.com/dote/article-lookup/doi/10.1093/dote/dow011. https://doi.org/10.1093/dote/dow011.CrossRefGoogle Scholar
- 99.••Teitelbaum EN, Dunst CM, Reavis KM, Sharata AM, Ward MA, DeMeester SR, et al. Clinical outcomes five years after POEM for treatment of primary esophageal motility disorders. Surg Endosc. 2017; https://doi.org/10.1007/s00464-017-5699-2. First study to report POEM outcomes with a mean follow-up time of 5 years, with a clinical success rate of 83%. They reported an improvement in the mean Eckardt scores at 6 months and 2 years, but there was a small but significant worsening of Eckardt scores at 5 years, emphasizing the importance of long-term follow-up in all patients.
- 100.Moonen A, Annese V, Belmans A, Bredenoord A, Bruley des Varannes S, Costantini M, et al. Long-term results of the European achalasia trial: a multicentre randomised controlled trial comparing pneumatic dilation versus laparoscopic Heller myotomy. Gut. 2016:732–9.Google Scholar
- 102.Familiari P, Greco S, Gigante G, Calì A, Boškoski I, Onder G, et al. Gastroesophageal reflux disease after peroral endoscopic myotomy: analysis of clinical, procedural and functional factors, associated with gastroesophageal reflux disease and esophagitis. Dig Endosc. 2016;28(1):33–41. https://doi.org/10.1111/den.12511.PubMedCrossRefGoogle Scholar
- 105.Rawlings A, Soper NJ, Oelschlager B, Swanstrom L, Matthews BD, Pellegrini C, et al. Laparoscopic Dor versus Toupet fundoplication following Heller myotomy for achalasia: results of a multicenter, prospective, randomized-controlled trial. Surg Endosc. 2012;26(1):18–26. https://doi.org/10.1007/s00464-011-1822-y.PubMedCrossRefGoogle Scholar
- 106.Csendes A, Braghetto I, Burdiles P, Korn O, Csendes P, Henríquez A. Very late results of esophagomyotomy for patients with achalasia: clinical, endoscopic, histologic, manometric, and acid reflux studies in 67 patients for a mean follow-up of 190 months. Ann Surg. 2006;243(2):196–203. https://doi.org/10.1097/01.sla.0000197469.12632.e0.PubMedPubMedCentralCrossRefGoogle Scholar