The POEM Procedure for Achalasia: From Outside to Inside in 100 Years

Originally presented as a Surgical Motion Picture at the 2015 STSA Annual Meeting

Objectives: Achalasia is an end stage motor disorder of the esophagus characterized by absent peristalsis and defective LES sphincter relaxation that results in patients experiencing progressive solid and liquid food dysphagia. Although there are many treatment options, surgical myotomy has produced effective and durable palliation. Per oral endoscopic myotomy (POEM) is a natural orifice approach used to perform myotomy that maintains the surgical principles that have developed over the last 100 years.

Methods: In this video, the authors review the evolution of the surgical myotomy and the innovations that have improved patient outcomes in achalasia. Both the myotomy and surgical approach have changed radically since Dr. Heller’s original report. An in-depth description of the POEM approach, including initial results, is shown.

Results: The myotomy for achalasia has evolved from a two sided myotomy, as described by Dr. Heller, to a short, single esophagomyotomy, as described by Dr. Zaaijer. The myotomy approach has moved from a transthoracic operation popularized by Dr. Ellis, to a thoracoscopic approach by Dr. Pellegrini, and then a laparoscopic approach by Dr. Patti that has been in use over the last 20 years. Extension onto the gastric wall by 2-3 cm results in less dysphagia. POEM is a surgical innovation by Dr. Inoue that is performed via a small mucosotomy in the wall of the esophagus to facilitate division of only the circular muscle layer. Initial results of 18 patients who underwent POEM demonstrated excellent palliation of swallowing and a low rate of GERD.

Conclusion: The approach to and the surgical myotomy for achalasia have changed radically over the last 100 years. Myotomy remains the gold standard treatment for achalasia. POEM is a natural evolution for surgeons to embrace, that adheres to existing surgical principles and achieves excellent palliation in swallowing with low rates of morbidity.

Copyright 2015, used with permission from the Southern Thoracic Surgical Association. All rights reserved.