Indications and Preoperative Workup for Peroral Endoscopic Myotomy
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In 2008, Dr. Haru Inoue described the clinical technique for peroral endoscopic myotomy (POEM) (Inoue et al., Endoscopy 42:265–271, 2010). POEM is based on the foundation of endoscopic submucosal dissection and the tunneling techniques for natural orifice translumenal endoscopic surgery (NOTES) which gained substantial enthusiasm in the mid–late 2000s. Since then POEM has been performed worldwide, safely and with reproducible outcomes, primarily for patients with achalasia. The indications for POEM are now expanding. This chapter will focus primarily on the preoperative workup for patients with achalasia, with a special emphasis on patient selection and preoperative objective evaluation with regard to POEM. Every patient with a presumed diagnosis of an esophageal motility disorder should ideally undergo a battery of esophageal diagnostic tests including a barium esophagogram, upper endoscopy, manometry, and in select cases, ambulatory pH impedance monitoring. Based on the workup, one may decide that a particular patient may not be an ideal candidate for POEM, or may indeed change the details of the operative procedure (such as the length of the myotomy). These caveats will be explored in this chapter.