POEM Contraindications and Pitfalls

  • Rani Modayil
  • Stavros N. StavropoulosEmail author


Peroral endoscopic myotomy (POEM), as the first Natural Orifice Transluminal Endoscopic Surgery (NOTES) procedure to gain widespread clinical success, represents a novel type of minimally invasive surgery outside the safe confines of the gastrointestinal lumen, and outside the comfort zone of most endoscopists, particularly gastroenterologists, who are unfamiliar with the hazards of surgery in their day-to-day practice. As such, it carries a much higher risk of severe or life-threatening complications than traditional therapeutic endoscopy. Furthermore, it requires a high level of skill as it attempts to replicate the results of a time-honored laparoscopic operation, the Heller myotomy, with much more basic tools than are available to the laparoscopic surgeon. It follows that in order to maximize efficacy and safety in this technically complex and risky undertaking, the operator needs to be acutely aware of potential pitfalls along with preventive and corrective strategies to address such pitfalls. These strategies consist of “tips and tricks” painstakingly acquired by pioneers and early adopters at high-volume centers, often via an arduous trial-and-error process. Unfortunately, this type of experiential practical information is hard to come by in the peer-reviewed literature which focuses heavily on evidence-based aggregate data to the point of near exclusion of empirical data. We hope that this chapter will help address this knowledge gap particularly for POEM operators early in their learning curve. We review the scant information regarding POEM pitfalls and contraindications gleaned from the literature and augment it with pitfalls, practical tips, and advice from our own extensive experience derived from the largest Western single-operator series at well over 300 POEMs spanning a period of 7 years.

Supplementary material

Video 7.1

(MP4 37349 kb)

Video 7.2

(MP4 480949 kb)

Video 7.3

(MP4 173343 kb)


  1. 1.
    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(9):3322–38. doi: 10.1007/s00464-013-2913-8.CrossRefPubMedGoogle Scholar
  2. 2.
    Khashab MA, Messallam AA, Onimaru M, Teitelbaum EN, Ujiki MB, Gitelis ME, Modayil RJ, Hungness ES, Stavropoulos SN, El Zein MH, Shiwaku H, Kunda R, Repici A, Minami H, Chiu PW, Ponsky J, Kumbhari V, Saxena P, Maydeo AP, Inoue H. 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. doi: 10.1016/j.gie.2014.10.011.CrossRefPubMedGoogle Scholar
  3. 3.
    Hoppo T, Thakkar SJ, Schumacher LY, Komatsu Y, Choe S, Shetty A, Bloomer S, Lloyd EJ, Zaidi AH, VanDeusen MA, Landreneau RJ, Kulkarni A, Jobe BA. A utility of peroral endoscopic myotomy (POEM) across the spectrum of esophageal motility disorders. Surg Endosc. 2016;30(1):233–44. doi: 10.1007/s00464-015-4193-y.CrossRefPubMedGoogle Scholar
  4. 4.
    Sharata AM, Dunst CM, Pescarus R, Shlomovitz E, Wille AJ, Reavis KM, Swanström LL. Peroral endoscopic myotomy (POEM) for esophageal primary motility disorders: analysis of 100 consecutive patients. J Gastrointest Surg. 2015;19(1):161–70. Discussion 170. doi: 10.1007/s11605-014-2610-5.
  5. 5.
    Badillo R, Francis D, DeVault K. Formation of large esophageal diverticulum after peroral endoscopic myotomy. Gastrointest Endosc. 2015;82(5):962. Discussion 963. doi: 10.1016/j.gie.2015.05.020.
  6. 6.
    Valdovinos MA, Zavala-Solares MR, Coss-Adame E. Esophageal hypomotility and spastic motor disorders: current diagnosis and treatment. Curr Gastroenterol Rep. 2014;16(11):421. doi: 10.1007/s11894-014-0421-1.CrossRefPubMedGoogle Scholar
  7. 7.
    Onimaru M, Inoue H, Ikeda H, Yoshida A, Santi EG, Sato H, Ito H, Maselli R, Kudo SE. 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(4):598–605. doi: 10.1016/j.jamcollsurg.2013.05.025.CrossRefPubMedGoogle Scholar
  8. 8.
    Zhou PH, Li QL, Yao LQ, Xu MD, Chen WF, Cai MY, Hu JW, Li L, Zhang YQ, Zhong YS, Ma LL, Qin WZ, Cui Z. Peroral endoscopic remyotomy for failed Heller myotomy: a prospective single-center study. Endoscopy. 2013;45(3):161–6. doi: 10.1055/s-0032-1326203.CrossRefPubMedGoogle Scholar
  9. 9.
    Vigneswaran Y, Yetasook AK, Zhao JC, Denham W, Linn JG, Ujiki MB. Peroral endoscopic myotomy (POEM): feasible as reoperation following Heller myotomy. J Gastrointest Surg. 2014;18(6):1071–6.CrossRefPubMedGoogle Scholar
  10. 10.
    Orenstein SB, Raigani S, Wu YV, Pauli EM, Phillips MS, Ponsky JL, Marks JM. Peroral endoscopic myotomy (POEM) leads to similar results in patients with and without prior endoscopic or surgical therapy. Surg Endosc. 2015;29(5):1064–70. doi: 10.1007/s00464-014-3782-5.CrossRefPubMedGoogle Scholar
  11. 11.
    Torquati A, Richards WO, Holzman MD, Sharp KW. Laparoscopic myotomy for achalasia: predictors of successful out- come after 200 cases. Ann Surg. 2006;243:587–91.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Kilic A, Schuchert MJ, Pennathur A, Gilbert S, Landreneau RJ, Luketich JD. Long-term outcomes of laparoscopic Heller myotomy for achalasia. Surgery. 2009;146(4):826–31. Discussion 831–3. doi: 10.1016/j.surg.2009.06.049.
  13. 13.
    Ravi K, Sweetser S, Katzka DA. Pseudoachalasia secondary to bariatric surgery. Dis Esophagus. 2016;29(8):992–5. doi: 10.1111/dote.12422.CrossRefPubMedGoogle Scholar
  14. 14.
    Ren Z, Zhong Y, Zhou P, Xu M, Cai M, Li L, Shi Q, Yao L. 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. doi: 10.1007/s00464-012-2336-y.CrossRefPubMedGoogle Scholar
  15. 15.
    Inoue H, Sato H, Ikeda H, Onimaru M, Sato C, Minami H, Yokomichi H, Kobayashi Y, Grimes KL, Kudo SE. Per-oral endoscopic myotomy: a series of 500 patients. J Am Coll Surg. 2015;221:256–64. doi: 10.1016/j.jamcollsurg.2015.03.057.CrossRefPubMedGoogle Scholar
  16. 16.
    Baldaque-Silva F, Marques M, Ramalho R, Vilas-Boas F, Afonso M, Macedo G. Case description of cap retention in the submucosal tunnel during peroral endoscopic myotomy. Am J Gastroenterol. 2012;107(10):1586. Author reply 1586. doi: 10.1038/ajg.2012.259.
  17. 17.
    Rieder E, Dunst CM, Perretta S, Donatelli G, Swanstrom LL. How to successfully manage novel technical challenges in per oral endoscopic myotomy for achalasia. Gastrointest Endosc. 2011;73(4S):AB104. doi: 10.1016/j.gie.2011.03.1224.Google Scholar
  18. 18.
    Mori H, Kobara H, Tsushimi T, Fujihara S, Nishiyama N, Matsunaga T, Ayaki M, Yachida T, Tani J, Miyoshi H, Morishita A, Masaki T. Reduction effect of bacterial counts by pre-operative saline lavage of the stomach in performing laparoscopic and endoscopic cooperative surgery. World J Gastroenterol. 2014;20:15763–70.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Teitelbaum EN, Soper NJ, Pandolfino JE, Kahrilas PJ, Hirano I, Boris L, Nicodème F, Lin Z, Hungness ES. Esophagogastric junction distensibility measurements during Heller myotomy and POEM for achalasia predict postoperative symptomatic outcomes. Surg Endosc. 2015;29(3):522–8. doi: 10.1007/s00464-014-3733-1.CrossRefPubMedGoogle Scholar
  20. 20.
    Lv L, Liu J, Tan Y, Liu D. Peroral endoscopic full-thickness myotomy for the treatment of sigmoid-type achalasia: outcomes with a minimum follow-up of 12 months. Eur J Gastroenterol Hepatol. 2016;28(1):30–6. doi: 10.1097/MEG.0000000000000491.CrossRefPubMedGoogle Scholar
  21. 21.
    Hu JW, Li QL, Zhou PH, Yao LQ, Xu MD, Zhang YQ, Zhong YS, Chen WF, Ma LL, Qin WZ, Cai MY. Peroral endoscopic myotomy for advanced achalasia with sigmoid-shaped esophagus: long-term outcomes from a prospective, single-center study. Surg Endosc. 2015;29(9):2841–50. doi: 10.1007/s00464-014-4013-9.CrossRefPubMedGoogle Scholar
  22. 22.
    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(10):3910. doi: 10.1007/s00464-013-3002-8.CrossRefPubMedGoogle Scholar
  23. 23.
    Zhai Y, Linghu E, Li H, Qin Z, Wang X, Du H, Meng J. Comparison of peroral endoscopic myotomy with transverse entry incision versus longitudinal entry incision for achalasia. Nan Fang Yi Ke Da Xue Xue Bao. 2013;33(9):1399–402.PubMedGoogle Scholar
  24. 24.
    Chai N, Linghu E, Zhang X, Yao G, Niu X. Simultaneous performance of one-tunnel per-oral endoscopic myotomy, submucosal tunneling endoscopic resection, and diverticulotomy. Gastrointest Endosc. 2016. 84(5):846–7. pii: S0016-5107(16)30171-7. doi:  10.1016/j.gie.2016.05.025.
  25. 25.
    Stavropoulos SN, Harris MD, Hida S, Brathwaite C, Demetriou C, Grendell J. Endoscopic submucosal myotomy for the treatment of achalasia (with video). Gastrointest Endosc. 2010;72(6):1309–11. doi: 10.1016/j.gie.2010.04.016.CrossRefPubMedGoogle Scholar
  26. 26.
    Modayil R, Stavropoulos SN. A western perspective on “New NOTES” from POEM to full-thickness resection and beyond. Gastrointest Endosc Clin N Am. 2016;26(2):413–32. doi: 10.1016/j.giec.2015.12.014.CrossRefPubMedGoogle Scholar
  27. 27.
    Teitelbaum EN, Soper NJ, Arafat FO, Santos BF, Kahrilas PJ, Pandolfino JE, Hungness ES. Analysis of a learning curve and predictors of intraoperative difficulty for peroral esophageal myotomy (POEM). J Gastrointest Surg. 2014;18(1):92–8. Discussion 98–9. doi: 10.1007/s11605-013-2332-0.
  28. 28.
    Cai MY, Zhou PH, Yao LQ, Xu MD, Zhong YS, Li QL, Chen WF, Hu JW, Cui Z, Zhu BQ. Peroral endoscopic myotomy for idiopathic achalasia: randomized comparison of water-jet assisted versus conventional dissection technique. Surg Endosc. 2014;28(4):1158–65.CrossRefPubMedGoogle Scholar
  29. 29.
    Ren Y, Tang X, Zhi F, Liu S, Wu J, Peng Y, Jiang B, Gong W. A stepwise approach for peroral endoscopic myotomy for treating achalasia: from animal models to patients. Scand J Gastroenterol. 2015;50(8):952–8. doi: 10.3109/00365521.2014.983152.CrossRefPubMedGoogle Scholar
  30. 30.
    Familiari P, Gigante G, Marchese M, Boskoski I, Tringali A, Perri V, Costamagna G. Peroral endoscopic myotomy for esophageal achalasia: outcomes of the first 100 patients with short-term follow-up. Ann Surg. 2016;263(1):82–7. doi: 10.1097/SLA.0000000000000992.CrossRefPubMedGoogle Scholar
  31. 31.
    Stavropoulos SN, Modayil RJ, Brathwaite C, Halwan B, Kollarus M, Taylor SI, Grendell JH. Outcomes of a large prospective series on per oral endoscopic myotomy (POEM) for achalasia: an effective and durable treatment modality that can safely be performed in the endoscopy suite. Gastrointest Endosc. 2016;83(5S):AB479–80. doi: 10.1016/j.gie.2016.03.666.Google Scholar
  32. 32.
    Bechara R, Onimaru M, Ikeda H, Inoue H. Per-oral endoscopic myotomy, 1000 cases later: pearls, pitfalls, and practical considerations. Gastrointest Endosc. 2016;84(2):330–8. doi: 10.1016/j.gie.2016.03.1469.CrossRefPubMedGoogle Scholar
  33. 33.
    Onimaru M, Inoue H, Ikeda H, Sato C, Sato H, Phalanusitthepha C, Santi EG, Grimes KL, Ito H, Kudo SE. Greater curvature myotomy is a safe and effective modified technique in per-oral endoscopic myotomy (with videos). Gastrointest Endosc. 2015;81(6):1370–7. doi: 10.1016/j.gie.2014.11.014.CrossRefPubMedGoogle Scholar
  34. 34.
    Stavropoulos SN, Iqbal S, Modayil R, Dejesus D. Per oral endoscopic myotomy, equipment and technique: a step-by-step explanation. Video J Encycl GI Endosc. 2013;1:96–100.CrossRefGoogle Scholar
  35. 35.
    Patel KS, Calixte R, Modayil RJ, Friedel D, Brathwaite CE, Stavropoulos SN. The light at the end of the tunnel: a single-operator learning curve analysis for per oral endoscopic myotomy. Gastrointest Endosc. 2015;81(5):1181–7. doi: 10.1016/j.gie.2014.10.002.CrossRefPubMedGoogle Scholar
  36. 36.
    Ramchandani M, Nageshwar Reddy D, Darisetty S, Kotla R, Chavan R, Kalpala R, Galasso D, Lakhtakia S, Rao GV. 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. doi: 10.1111/den.12495.CrossRefPubMedGoogle Scholar
  37. 37.
    Onimaru M, Inoue H, Ikeda H, Yoshida A, Santi EG, Sato H, Ito H, Maselli R, Kudo SE. 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(4):598–605. doi: 10.1016/j.jamcollsurg.2013.05.025.CrossRefPubMedGoogle Scholar
  38. 38.
    Liu BR, Song JT, Omar JM. Video of the month. Modified peroral endoscopic myotomy. Am J Gastroenterol. 2015;110(4):499. doi: 10.1038/ajg.2015.9.CrossRefPubMedGoogle Scholar
  39. 39.
    Philips GM, Dacha S, Keilin SA, Willingham FF, Cai Q. Concurrent myotomy and tunneling after establishment of a half tunnel instead of myotomy after establishment of a full tunnel: a more efficient method of peroral endoscopic myotomy. Endosc Int Open. 2016;4(4):E403–8. doi: 10.1055/s-0042-101787.CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Teitelbaum EN, Boris L, Arafat FO, Nicodème F, Lin Z, Kahrilas PJ, Pandolfino JE, Soper NJ, Hungness ES. Comparison of esophagogastric junction distensibility changes during POEM and Heller myotomy using intraoperative FLIP. Surg Endosc. 2013;27(12):4547–55. doi: 10.1007/s00464-013-3121-2.CrossRefPubMedGoogle Scholar
  41. 41.
    Bechara R, Onimaru M, Ikeda H, Inoue H. Per-oral endoscopic myotomy, 1000 cases later: pearls, pitfalls, and practical considerations. Gastrointest Endosc. 2016;84(2):330–8. doi: 10.1016/j.gie.2016.03.1469.CrossRefPubMedGoogle Scholar
  42. 42.
    NOSCAR POEM White Paper Committee, Stavropoulos SN, Desilets DJ, Fuchs KH, Gostout CJ, Haber G, Inoue H, Kochman ML, Modayil R, Savides T, Scott DJ, Swanstrom LL, Vassiliou MC. Per-oral endoscopic myotomy white paper summary. Gastrointest Endosc. 2014;80(1):1–15. doi: 10.1016/j.gie.2014.04.014.CrossRefGoogle Scholar
  43. 43.
    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(6):1169–70. doi: 10.1016/j.gie.2014.03.035.CrossRefPubMedGoogle Scholar
  44. 44.
    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:E215–6. doi:  10.1055/s-0032-1309358.
  45. 45.
    Ling T, Pei Q, Pan J, Zhang X, Lv Y, Li W, Zou X. Successful use of a covered, retrievable stent to seal a ruptured mucosal flap safety valve during peroral endoscopic myotomy in a child with achalasia. Endoscopy. 2013;45 Suppl 2 UCTN:E63–4. doi:  10.1055/s-0032-1325977.
  46. 46.
    Stavropoulos SN, Modayil RJ, Brathwaite C, Halwan B, Kollarus M, Taylor SI, Friedel D, Grendell JH. Anterior vs posterior peroral endoscopic myotomy (POEM): is there a difference in outcomes? Gastrointest Endosc. 2016;83(5S):AB145. doi: 10.1016/j.gie.2016.03.089.CrossRefGoogle Scholar
  47. 47.
    Oelschlager BK, Chang L, Pellegrini CA. Improved outcome after extended gastric myotomy for achalasia. Arch Surg. 2003;138:490–5.CrossRefPubMedGoogle Scholar
  48. 48.
    Teitelbaum EN, Sternbach JM, El Khoury R, Soper NJ, Pandolfino JE, Kahrilas PJ, Lin Z, Hungness ES. The effect of incremental distal gastric myotomy lengths on EGJ distensibility during POEM for achalasia. Surg Endosc. 2016;30(2):745–50. doi: 10.1007/s00464-015-4269-8.CrossRefPubMedGoogle Scholar
  49. 49.
    Kumbhari V, Besharati S, Abdelgelil A, Tieu AH, Saxena P, El-Zein MH, Ngamruengphong S, Aguila G, Kalloo AN, Khashab MA. Intraprocedural fluoroscopy to determine the extent of the cardiomyotomy during per-oral endoscopic myotomy (with video). Gastrointest Endosc. 2015;81(6):1451–6. doi: 10.1016/j.gie.2015.01.052.CrossRefPubMedGoogle Scholar
  50. 50.
    Baldaque-Silva F, Marques M, Vilas-Boas F, Maia JD, Sá F, Macedo G. New transillumination auxiliary technique for peroral endoscopic myotomy. Gastrointest Endosc. 2014;79(4):544–5. doi: 10.1016/j.gie.2013.10.023.CrossRefPubMedGoogle Scholar
  51. 51.
    Grimes KL, Inoue H, Onimaru M, Ikeda H, Tansawet A, Bechara R, Tanaka S. Double-scope per oral endoscopic myotomy (POEM): a prospective randomized controlled trial. Surg Endosc. 2016;30(4):1344–51. doi: 10.1007/s00464-015-4396-2.CrossRefPubMedGoogle Scholar
  52. 52.
    Li QL, Chen WF, Zhou PH, Yao LQ, Xu MD, Hu JW, Cai MY, Zhang YQ, Qin WZ, Ren Z. 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. doi: 10.1016/j.jamcollsurg.2013.04.033.CrossRefPubMedGoogle Scholar
  53. 53.
    Banks-Venegoni AL, Desilets DJ, Romanelli JR, Earle DB. Tension capnopericardium and cardiac arrest as an unexpected adverse event of peroral endoscopic myotomy (with video). Gastrointest Endosc. 2015;82(6):1137–9. doi: 10.1016/j.gie.2015.07.028.CrossRefPubMedGoogle Scholar
  54. 54.
    Saleem AM, Hennessey H, von Renteln D, Vassiliou MC. Atrial fibrillation as an unexpected complication after peroral endoscopic myotomy (POEM): a case report. Surg Laparosc Endosc Percutan Tech. 2014;24(5):e196–9. doi: 10.1097/SLE.0000000000000094.CrossRefPubMedGoogle Scholar
  55. 55.
    Fox MR, Pandolfino JE, Sweis R, Sauter M, Abreu Y, Abreu AT, Anggiansah A, Bogte A, Bredenoord AJ, Dengler W, Elvevi A, Fruehauf H, Gellersen S, Ghosh S, Gyawali CP, Heinrich H, Hemmink M, Jafari J, Kaufman E, Kessing K, Kwiatek M, Lubomyr B, Banasiuk M, Mion F, Pérez-de-la-Serna J, Remes-Troche JM, Rohof W, Roman S, Ruiz-de-León A, Tutuian R, Uscinowicz M, Valdovinos MA, Vardar R, Velosa M, Waśko-Czopnik D, Weijenborg P, Wilshire C, Wright J, Zerbib F, Menne D. Inter-observer agreement for diagnostic classification of esophageal motility disorders defined in high-resolution manometry. Dis Esophagus. 2015;28(8):711–9. doi: 10.1111/dote.12278.CrossRefPubMedGoogle Scholar
  56. 56.
    Li QL, Zhou PH, Yao LQ, Xu MD, Chen WF, Hu JW, Cai MY, Zhang YQ, Zhong YS, Qin WZ, He MJ. Early diagnosis and management of delayed bleeding in the submucosal tunnel after peroral endoscopic myotomy for achalasia (with video). Gastrointest Endosc. 2013;78(2):370–4. doi: 10.1016/j.gie.2013.04.172.CrossRefPubMedGoogle Scholar
  57. 57.
    Ponsky JL, Marks JM, Orenstein SB. Retrograde myotomy: a variation in per oral endoscopic myotomy (POEM) technique. Surg Endosc. 2014;28(11):3257–9. doi: 10.1007/s00464-014-3568-9.CrossRefPubMedGoogle Scholar
  58. 58.
    Saxena P, Chavez YH, Kord Valeshabad A, Kalloo AN, Khashab MA. An alternative method for mucosal flap closure during peroral endoscopic myotomy using an over-the-scope clipping device. Endoscopy. 2013;45:579–81.CrossRefPubMedGoogle Scholar
  59. 59.
    Stavropoulos SN, Modayil R, Friedel D. Current applications of endoscopic suturing. World J Gastrointest Endosc. 2015;7:777–89.PubMedPubMedCentralGoogle Scholar
  60. 60.
    Pescarus R, Shlomovitz E, Sharata AM, Cassera MA, Reavis KM, Dunst CM, Swanström LL. Endoscopic suturing versus endoscopic clip closure of the mucosotomy during a per-oral endoscopic myotomy (POEM): a case-control study. Surg Endosc. 2016;30(5):2132–5. doi: 10.1007/s00464-015-4464-7.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG 2017

Authors and Affiliations

  1. 1.Division of Digestive and Liver DiseasesProgram for Advanced GI Endoscopy (PAGE), Winthrop University HospitalMineolaUSA

Personalised recommendations