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Peroral endoscopic myotomy or POEM is an endoscopic procedure performed to treat swallowing disorders such as achalasia and esophageal spasms. It is a newly developed invasive technique that takes nearly one to three hours to complete. The main advantage of this technique is that there are no incisions in the chest or abdomen and requires a minimum hospital stay. Very few countries are offering this less-invasive approach to treat swallowing disorders.
Achalasia is a condition in which lower esophageal sphincter (a valve which allows food to pass from the esophagus into the stomach) fails to open up during swallowing, resulting in back up of food within the esophagus. This is mainly caused by damage to the esophageal nerves. People with achalasia often experience trouble while swallowing food which may lead to coughing, choking, and burning in the chest etc. There is no cure for achalasia, however, the symptoms can be managed with various treatment options such as medications, balloon dilatation, botulinum toxin injection. However, these are considered as less invasive techniques when compared to POEM due to low efficacy and high complication rates.
PROCEDURE OF POEM
Apart from achalasia, POEM is indicated for other conditions like diffuse esophageal spasms (a condition characterized by uncoordinated contractions of the esophagus) and jackhammer esophagus (intense esophageal spasms). PEOM is the only treatment option when other surgical techniques failed to manage the conditions.
Before the surgery
To prepare for the surgery, the patient should follow certain instructions like:
During the surgery
After taking to the operating room, the patient will be given anesthesia and antibiotics intravenously. POEM is performed under general anesthesia and hence the patient will be asleep throughout the procedure.
An endoscope which is a long, thin tube is inserted into the esophagus through the mouth. A small camera attached to the end of the tube helps the doctor to monitor and control the endoscope.
Using a specific knife placed at the end of the endoscopic tube, the doctor makes incision in the internal lining of the esophagus to permit entry to the wall of the esophagus where muscle is exposed. Then the inner layer of the muscle near the lower esophageal sphincter will be cut to loosen the tight esophageal muscles that are responsible for the swallowing problems. This is called myotomy. The muscles on sides of the esophagus, the lower esophageal sphincter and the upper part of the stomach are cut and loosened. After this step, the esophageal incision will be closed with standard endoscopic clips that are inserted at the lining of the esophagus. The endoscopic tube is then removed through the mouth.
This procedure relieves the tightness of the esophageal muscles and allows the food to pass into the stomach normally.
The patient should stay in the hospital for one night to check if there any complications related to the surgery. The patient will not be allowed to eat or drink anything for the day following the surgery. The next day, barium test will be performed to check if the esophagus muscle is open and there is no leakage. If the patient passes the test, liquid diet will be given.
Intravenous antibiotics will be discontinued three days after the procedure; they should be taken orally for another 7 days. The evaluation tests like manometry, pH metry, and endoscopy are repeated for every 3 to 6 months to check the efficacy, complications, and side effects (if any) of the procedure.
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