Surgical Management of Achalasia: Peroral Endoscopic Myotomy

  • Joel Sternbach
  • Eric HungnessEmail author


A novel procedure, combining the decreased invasiveness of endoscopic access with the reliability of a surgical myotomy, peroral endoscopic myotomy (POEM), represents a potential paradigm shift in the management of idiopathic achalasia and other esophageal motor disorders. Comprehensive preoperative evaluation by a multidisciplinary team of gastroenterologists and surgeons is essential to confirming candidacy for POEM and appropriately counseling patients on expected outcomes and postoperative outcomes, including the lack of long-term outcome data. The key steps of the procedure are detailed, including initial EGD, safe access to the submucosal space, creation of a submucosal tunnel extending at least 3 cm onto the gastric cardia, selective myotomy of the inner circular muscle fibers, and closure of the mucosotomy. Frequently encountered complications include bleeding, inadvertent mucosotomy, full-thickness perforation, and development of capnothorax and/or capnoperitoneum.


POEM Achalasia NOTES Myotomy Dysphagia 



Diffuse esophageal spasm


Distensibility index




Esophagogastric junction


Endoscopic mucosal resection


Esophageal pressure topography


Eckardt score


Endoscopic submucosal dissection


Functional lumen imaging probe


Gastroesophageal reflux disease


High-resolution impedance manometry


High-resolution manometry


Impaction-dysphagia questionnaire, GERDQ


Lower esophageal sphincter


Natural orifice transluminal endoscopic surgery


Peroral endoscopic myotomy


Timed barium esophagram


Visceral sensitivity index


  1. 1.
    Mayberry JF. Epidemiology and demographics of achalasia. Gastrointest Endosc Clin N Am. 2001;11:235–48.CrossRefGoogle Scholar
  2. 2.
    Kahrilas PJ, Boeckxstaens G. The spectrum of achalasia: lessons from studies of pathophysiology and high-resolution manometry. Gastroenterology. 2013;145(5):954–65. PMID: 23973923 PMCID: PMC3835179.CrossRefGoogle Scholar
  3. 3.
    Moonen A, Boeckxstaens G. Current diagnosis and management of achalasia. J Clin Gastroenterol. 2014;48(6):484–90.PubMedGoogle Scholar
  4. 4.
    Kandulski A, Fuchs KH, Weigt J, Malfertheiner P. Jackhammer esophagus: high-resolution manometry and therapeutic approach using peroral endoscopic myotomy (POEM). Dis Esophagus. 2014;27:PMID: 24460870.Google Scholar
  5. 5.
    Minami H, Inoue H, Haji A, Isomoto H, Urabe S, Hashiguchi K, et al. Per-oral endoscopic myotomy: emerging indications and evolving techniques. Dig Endosc. 2014;27(2):175–81. [Epub ahead of print].CrossRefGoogle Scholar
  6. 6.
    Stavropoulos SN, Modayil R, Friedel D, et al. The International Per Oral Endoscopic Myotomy Survey (IPOEMS): a snapshot of the global POEM experience. Surg Endosc. 2013;27:3322–38.CrossRefGoogle Scholar
  7. 7.
    Fisichella PM, Patti MG. From Heller to POEM (1914–2014): A 100-year history of surgery for achalasia. J Gastrointest Surg. 2014;18(10):1870–5. [Epub ahead of print].CrossRefGoogle Scholar
  8. 8.
    Pasricha PJ, Hawari R, Ahmed I, et al. Submucosal endoscopic esophageal myotomy: a novel experimental approach for the treatment of achalasia. Endoscopy. 2007;39:761–4.CrossRefGoogle Scholar
  9. 9.
    Rajan E, Gostout CJ, Feitoza AB, et al. Widespread EMR: a new technique for removal of large areas of mucosa. Gastrointest Endosc. 2004;60:623–7.CrossRefGoogle Scholar
  10. 10.
    Inoue H, Minami H, Kobayashi Y, et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy. 2010;42:265–71.CrossRefGoogle Scholar
  11. 11.
    Eckardt VF. Clinical presentations and complications of achalasia. Gastrointest Endosc Clin N Am. 2001;11(2):281–92, vi. Pubmed PMID: 11319062.CrossRefGoogle Scholar
  12. 12.
    Hungness ES, Teitelbaum EN, Santos BF, et al. Comparison of perioperative outcomes between Peroral Esophageal Myotomy (POEM) and laparoscopic Heller Myotomy. J Gastrointest Surg. 2012;17(2):228–35.CrossRefGoogle Scholar
  13. 13.
    Harnish JL, Darling GE, Diamant NE, et al. Patient-centered measures for achalasia. Surg Endosc. 2008;22(5):1290–3.CrossRefGoogle Scholar
  14. 14.
    Schlottmann F, Neto RML, Herbella FAM, Patti MG. Esophageal achalasia: pathophysiology, clinical presentation, and diagnostic evaluation. Am Surg. 2018;84(4):467–72.PubMedGoogle Scholar
  15. 15.
    Rohof WO, Salvador R, Annese V, et al. Outcomes of treatment for achalasia depend on manometric subtype. Gastroenterology. 2012;144(4):718–25. PubMed PMID: 23277105.CrossRefGoogle Scholar
  16. 16.
    Rohof WO, Hursch DP, Kessing BF, et al. Efficacy of treatment for patients with achalasia depends on the distensibility of the esophagogastric junction. Gastroenterology. 2012;143(2):328–35.CrossRefGoogle Scholar
  17. 17.
    Kurian AA, Dunst CM, Sharata A, Bhayani NH, Reavis KM, Swanström LL. Peroral endoscopic esophageal myotomy: defining the learning curve. Gastrointest Endosc. 2013;77(5):719–25.CrossRefGoogle Scholar
  18. 18.
    Kandulski A, et al. Jackhammer esophagus: high-resolution manometry and therapeutic approach using peroral endoscopic myotomy (POEM). Dis Esophagus. 2014;29(6):695–6.CrossRefGoogle Scholar
  19. 19.
    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. [Epub ahead of print] PubMed PMID: 24830579.CrossRefGoogle Scholar
  20. 20.
    Vaezi MF, Baker ME, Achkar E, et al. Timed barium oesophagram: better predictor of long term success after pneumatic dilation in achalasia than symptom assessment. Gut. 2002;50:765–70.CrossRefGoogle Scholar
  21. 21.
    von Renteln D, Fuchs KH, Fockens P, et al. Peroral endoscopic myotomy for the treatment of achalasia: an international prospective multicenter study. Gastroenterology. 2013;145:309–11.CrossRefGoogle Scholar
  22. 22.
    Werner YB, Costamanga G, Swanstrom LL, et al. Clinical response to peroral endoscopic myotomy in patients with idiopathic achalasia as a minimum follow-up of 2 years. Gut. 2016;65:899–906.CrossRefGoogle Scholar
  23. 23.
    Hungness EH, Sternbach JM, Teitelbaum EN, et al. Per-oral endoscopic myotomy (POEM) after the learning curve: durable long-term results with a low complication rate. Ann Surg. 2016;264:508–17.CrossRefGoogle Scholar
  24. 24.
    Ngamruengphong S, Inoue H, Chiu PW, 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. 2016;85(5):927–933.e2.CrossRefGoogle Scholar
  25. 25.
    Inoue H, Sato H, Ikeda H, et al. Per-oral endoscopic myotomy: a series of 500 patients. J Am Coll Surg. 2015;221:256–64.CrossRefGoogle Scholar
  26. 26.
    Richards WO, Torquati A, Holzman MD, Khaitan L, Byrne D, Lutfi R, et al. Heller myotomy versus Heller myotomy with Dor fundoplication for achalasia: a prospective randomized double-blind clinical trial. Ann Surg. 2004;240(3):405–12.CrossRefGoogle Scholar
  27. 27.
    Rebecchi F, Giaccone C, Farinella E, Campaci R, Morino M. Randomized controlled trial of laparoscopic Heller myotomy plus Dor fundoplication versus Nissen fundoplication for achalasia: long-term results. Ann Surg. 2008;248(6):1023–30.CrossRefGoogle Scholar
  28. 28.
    Rawlings A, Soper NJ, Oelschlager B, et al. Laparoscopic Dor versus Toupet fundoplication following Heller myotomy for achalasia: results of a multicenter, prospective, randomized-controlled trial. Surg Endosc. 2012;26:18–26.CrossRefGoogle Scholar

Copyright information

© SAGES 2019

Authors and Affiliations

  1. 1.Department of SurgeryNorthwestern Memorial HospitalChicagoUSA

Personalised recommendations