Gastroenterologists Consider Novel Procedure of POEM

Although the introduction of peroral endoscopic myotomy (POEM) for the treatment of achalasia, a condition that affects the ability of the esophagus to move food into the stomach, has caused quite a stir, clinicians are reminded to consider additional factors when discussing therapeutic options.

Felice Schnoll-Sussman, MD, said “POEM appears safe and effective in early reports in the literature. But expertise is variable, and its place in the armamentarium remains unclear.”

Although this treatment eliminates the need for a traditional surgical procedure, no treatment can restore peristalsis to the esophageal body. An important recent advance in achalasia treatment is the availability of high-resolution esophageal manometry (HRM), which ultimately changed how achalasia is diagnosed.

Schnoll-Sussman said, “It has changed the way we look at esophageal motility by allowing for a more detailed assessment of peristalsis and the lower esophageal sphincter pressure. We can now quantify the adequacy of relaxation at the esophagogastric junction, the integrated relaxation pressure (IRP).”

Research has shown that achalasia could be distributed into 3 clinical subtypes, which according to Schnoll-Sussman, “Is important because the different subtypes may respond differently to various treatments.”

According to an article in Gastroenterology & Endoscopy News, 3 different nonsurgical treatment options have been brought developed. Two of the methods (botox and pneumatic dilation) are most suitable for patients with short life expectancies or who are poor surgical candidates. While they both provide successful results, their effects are often short lived. The third option, POEM, is a natural orifice transluminal endoscopic surgery (NOTES) approach to myotomy, which made its US debut in 2009. For this procedure, the surgeon inserts the endoscope into the submucosa through the hole and dissects a tunnel within the submucosa down to the gastric cardia.

Schnoll-Sussman noted that we are not yet at a point to confirm every patient should be offered a POEM. “There is variability in the way people are trained, in the way it’s performed, in the length of the myotomy and in whom it’s offered to — these are all important things to consider,” said Schnoll-Sussman.

“With POEM, gastroenterologists are learning to linger in the previously taboo spaces of the mediastinum and peritoneum. In the very precise, standardized steps of POEM, they get increasingly confident with managing insufflation-related complications and closing large perforations — the essential skills for NOTES,” she said. “POEM opens the door to a whole new world of NOTES interventions and POEM offshoots.”