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Steps of the POEM procedure. (A) Mucosotomy. (B) Submucosal tunnel. (C) Myotomy. (D) Closure of the mucosotomy.
Source publication
Achalasia is progressive neurodegenerative disorder of the esophagus, resulting in uncoordinated esophageal motility and failure of lower esophageal sphincter relaxation, leading to impaired swallowing. Surgical myotomy of the lower esophageal sphincter, either open or minimally invasive, has been a standard of care for the past several decades. Re...
Contexts in source publication
Context 1
... standard POEM technique consists of four sequential steps: 1: mucosotomy (initial mucosal entry), 2: submucosal tunneling, 3: myotomy proper, and 4: closure of the mucosal defect ( Figure 4) (13,15,16). The mucosal site entry is usually performed 10-15 cm proximal to the GEJ. ...
Context 2
... mucosal site entry is usually performed 10-15 cm proximal to the GEJ. After creating a submucosal cushion with saline and blue dye mixture, a 2 cm mucosal incision is created for entry into the submucosal plane ( Figure 4A). Subsequently, alternating saline injection with energy dissection, a submucosal tunnel is created. ...
Context 3
... submucosal blood vessels can be individually coagulated for prevention of bleeding. The submucosal tunnel is extended approximately 3 cm distal to the GEJ to ensure complete disruption of the LES ( Figure 4E). Once the submucosal tunnel has been completed, the myotomy is performed, starting 3 to 5 cm distally to the site of the mucosotomy ( Figure 4C). ...
Context 4
... submucosal tunnel is extended approximately 3 cm distal to the GEJ to ensure complete disruption of the LES ( Figure 4E). Once the submucosal tunnel has been completed, the myotomy is performed, starting 3 to 5 cm distally to the site of the mucosotomy ( Figure 4C). The optimal depth of the myotomy is not known. ...
Context 5
... the myotomy is complete, a careful inspection of the mucosa is performed to detect inadvertent mucosal defects. Endoscopic hemostatic clip closure or an endoluminal suturing device is used to seal the site of mucosal entry ( Figure 4D) (13). ...
Context 6
... success of POEM gave rise to similar procedures for the treatment of other conditions. Procedure equivalent to the surgical pyloromyotomy, termed gastric peroral endoscopic myotomy (G-POEM), also known as peroral pyloromyotomy (POP) is developed for the treatment of refractory gastroparesis ( Figure 6A) (45,47,49). For G-POEM procedure a submucosal tunnel is typically created 5 cm proximal to the pylorus along the greater curvature or anterior gastric wall and a pyloromyotomy with short antral myotomy is performed. ...
Context 7
... standard POEM technique consists of four sequential steps: 1: mucosotomy (initial mucosal entry), 2: submucosal tunneling, 3: myotomy proper, and 4: closure of the mucosal defect ( Figure 4) (13,15,16). The mucosal site entry is usually performed 10-15 cm proximal to the GEJ. ...
Context 8
... mucosal site entry is usually performed 10-15 cm proximal to the GEJ. After creating a submucosal cushion with saline and blue dye mixture, a 2 cm mucosal incision is created for entry into the submucosal plane ( Figure 4A). Subsequently, alternating saline injection with energy dissection, a submucosal tunnel is created. ...
Context 9
... submucosal blood vessels can be individually coagulated for prevention of bleeding. The submucosal tunnel is extended approximately 3 cm distal to the GEJ to ensure complete disruption of the LES ( Figure 4E). Once the submucosal tunnel has been completed, the myotomy is performed, starting 3 to 5 cm distally to the site of the mucosotomy ( Figure 4C). ...
Context 10
... submucosal tunnel is extended approximately 3 cm distal to the GEJ to ensure complete disruption of the LES ( Figure 4E). Once the submucosal tunnel has been completed, the myotomy is performed, starting 3 to 5 cm distally to the site of the mucosotomy ( Figure 4C). The optimal depth of the myotomy is not known. ...
Context 11
... the myotomy is complete, a careful inspection of the mucosa is performed to detect inadvertent mucosal defects. Endoscopic hemostatic clip closure or an endoluminal suturing device is used to seal the site of mucosal entry ( Figure 4D) (13). ...
Context 12
... success of POEM gave rise to similar procedures for the treatment of other conditions. Procedure equivalent to the surgical pyloromyotomy, termed gastric peroral endoscopic myotomy (G-POEM), also known as peroral pyloromyotomy (POP) is developed for the treatment of refractory gastroparesis ( Figure 6A) (45,47,49). For G-POEM procedure a submucosal tunnel is typically created 5 cm proximal to the pylorus along the greater curvature or anterior gastric wall and a pyloromyotomy with short antral myotomy is performed. ...
Citations
... Currently, post-procedure care varies per hospital and routine esophagram 1 day post-POEM still is often performed [27,31]. Five of 154 patients had signs of esophageal leakage on routine esophagram, of which two were indicated as clinically relevant and repeat endoscopy was performed to close the leakage with additional clips. ...
Background Peroral endoscopic myotomy (POEM) is highly successful in treating patients with achalasia. The aim of this study was to evaluate the incidence of early adverse events (AEs) following POEM and to assess whether post-procedural imaging by routine esophagram prevents serious AEs due to early detection of esophageal leakage after POEM. Methods Patients who underwent POEM between August 2011 and December 2022 were included in this retrospective cohort study. Post-procedural AEs were graded according to the AGREE classification. Until July 2016 routine esophagram was routinely performed one day after POEM, afterwards this was abandoned. The number and severity of post-procedural AEs were compared between patients with and without routine esophagram after POEM. Results In total, 352 patients were included (mean age 47 years, 48.3% female). Nineteen post-procedural AEs occurred of which ten were grade I (2.8%), three grade II (0.9%), five grade IIIa (1.4%) and one grade IVa (0.3%). No difference was found in the number and severity of post-procedural AEs between patients with and without routine esophagram . In 129 patients routine esophagram was performed one day after POEM. In two patients esophageal leakage was seen after which repeat endoscopy was performed to close the incision with additional clips. After abolishing routine esophagram from the protocol, no AEs led to severe complications related to esophageal leakage. Conclusion POEM is safe with relatively low number of AEs. The benefit of routine esophagram one day after POEM is limited as it does not prevent serious complications resulting from esophageal leakage.
... Treatment of symptomatic achalasia includes medical therapy with botulinum toxin injection and oral nitrates or surgical methods that lead to symptomatic resolution, including pneumatic dilation, laparoscopic heller myotomy (LHM), and its endoscopic equivalent, POEM [2]. POEM and LHM are utilized for treatment-resistant achalasia, and although both are comparably effective in the resolution of symptoms with a success rate of 90%, studies show that POEM is more cost-effective and associated with less postoperative pain than its laparoscopic counterpart [3,4]. In a study by Ujiki et al., 18 patients underwent POEM and 21 underwent LHM. ...
... The POEM procedure consists of four steps: (i) mucosotomy, which is performed 10 to 15 centimeters proximal to the gastroesophageal junction (GEJ); (ii) submucosal tunneling, which is extended distal to the GEJ to ensure complete disruption of the LES and expands the space between the muscularis propria and mucosa; (iii) myotomy proper with preservation of the outer longitudinal muscular layer; and (iv) closure of the mucosal defect with hemostatic clips or an endoluminal suturing device [3]. This procedure treats achalasia by decreasing the LES resting pressure, allowing the passage of the ingested material [1]. ...
Per-oral endoscopic myotomy (POEM) is a minimally invasive procedure that is very effective in the treatment of achalasia, a rare esophageal motility disorder. POEM has become the first-line treatment for achalasia, with high success rates reported in the literature. However, a known complication of POEM is gastroesophageal reflux disease (GERD). The exact cause and risk factors of post-POEM GERD are not fully understood; however, a number of factors have played a role in its development. The management of post-POEM GERD is mainly by conservative measures, such as lifestyle changes and medications, like proton pump inhibitors (PPI), which are often the first-line method of treatment. However, surgical procedures, such as fundoplication, may be necessary in some patients. This literature review will discuss the effectiveness of the use of PPIs as a management strategy for post-POEM GERD, the factors that lead to PPI-resistant GERD, and other management strategies utilized in these cases.
... При оценке дисфагии по шкале Eckardt перед вмешательством среднее значение составило (11,19 (10,0; 12,0) (от 9 до 12 баллов). Вмешательства выполнялись по стандартному протоколу (осмотр, инъекция раствора в подслизистый слой, разрез слизистой оболочки, формирование тоннеля с перехода на желудок, миотомия, клипирование разреза слизистой оболочки) по передней (у 40 пациентов) или задней стенке (у 70), в операционной под эндотрахеальным наркозом с использованием эндоскопов Olympus (Япония) (150 и 180 серия) с инсуффляцией углекислого газа (Olympus (Япония)). ...
... С момента первой публикации о результатах ПОЭМ в 2010 году произошла смена парадигмы лечения пациентов с ахалазией пищевода. В ряде публикаций ПОЭМ стала «золотым» стандартом лечения пациентов с ахалазией пищевода из-за ее высокого профиля эффективности, безопасности, ближайших и отдаленных функциональных результатов [1,[10][11][12][13]. По нашим данным, техническая возможность вмешательства составила 99,09%, что совпадает с данными многих авторов [2,5,[8][9][10][11][12][13][14]. ...
... В ряде публикаций ПОЭМ стала «золотым» стандартом лечения пациентов с ахалазией пищевода из-за ее высокого профиля эффективности, безопасности, ближайших и отдаленных функциональных результатов [1,[10][11][12][13]. По нашим данным, техническая возможность вмешательства составила 99,09%, что совпадает с данными многих авторов [2,5,[8][9][10][11][12][13][14]. ...
The purpose of the study is analyze of the results of peroral endoscopic myotomy in patients with esophageal achalasia. Material and methods. In the period 2017-2022 years peroral endoscopic myotomy in esophageal achalasia was performed in 110 patients (43 - men, 77 - women). Mean aged from 7 to 75 years. The duration of the disease ranged from 6 months to 40 years. Results. In 109 cases, the intervention was technically successful. The intervention was not successful due to the severity of fibrosis in the submucosal layer in 1 patient. The operation time ranged from 45 to 195 minutes. Complications during the intervention were in 9 (8,18%) patients. In the postoperative period, in 4 (3,63%) patients had complications that were eliminated by using flexible endoscopes. Patients were discharged from the hospital 3-5 days after the operation. There were not re-interventions performed. Erosive reflux esophagitis is the most common condition in the postoperative period. This condition was successfully stopped by inhibitors proton pump taking. When examining in the postoperative period and assessing the level quality of life using questionnaires SF-36, GIQLI and the Eckardt scale noted relief of dysphagia and a significant improvement in the main indicators. Conclusion. Peroral endoscopic myotomy in patients with esophageal achalasia can be the operation of choice in terms of efficiency, safety and long-term results, the level of quality of life in the postoperative period. To assess the long-term results of the intervention in this category of patients, further monitoring is required.
... Pneumatic balloon dilation and surgical cardiomyotomy are gold standard interventions for management of achalasia (27,28). In the last decade, perioral endoscopic myotomy (POEM) has emerged as a safe, minimally invasive technique used in the treatment of these patients. ...
Objective:
The current article describes modern endoscopic technologies that allow for advanced endoscopic tissue approximation and suturing. These technologies include such devices as through the scope and over the scope clips, endoscopic suturing OverStitch device and through the scope suturing X-Tack device.
Background:
Since the original introduction of the diagnostic endoscopy, progress in the field has been astonishing. Over the past several decades endoscopy has made numerous advancements allowing for a minimally invasive mechanism to treat life threatening conditions such as gastrointestinal (GI) bleeding, full thickness injuries, as well as chronic medical conditions such as morbid obesity and achalasia.
Methods:
A narrative review of all relevant and available literature on endoscopic tissue approximation devices over the last 15 years ago was conducted.
Conclusions:
Multiple new devices, including endoscopic clips and endoscopic suturing devices, have been developed for endoscopic tissue approximation that allow advanced endoscopic management of a wide variety of GI tract conditions. It is critical for practicing surgeons to actively participate in the development and use of these new technologies and devices in order to maintain leadership in the field, hone expertise, and to drive innovation. Further research in minimally invasive applications for these devices is needed as they continue to be refined. This article provides a general overview of the devices available and their clinical applications.
Amaç: Bu çalışma, akalazya tanısı almış yetişkin hastalarda POEM prosedürünün etkinlik ve komplikasyonlar açısından sonuçlarını sunmayı ve yaş, cinsiyet ve obezite gibi geleneksel risk faktörlerinin bu sonuçlar üzerindeki potansiyel etkilerini araştırmayı amaçlamaktadır. Gereç ve Yöntemler: Ocak 2021'den Temmuz 2023'e kadar POEM prosedürü geçiren toplam 51 hasta geriye dönük olarak değerlendirildi. Ana sonlanım noktası, prosedürden iki ay sonra Eckardt skorunun 3 veya daha düşük olmasıyla belirlenen klinik başarı oranı olarak değerlendirildi. İkincil sonlanım noktaları, herhangi bir advers olay, yoğun bakım ünitesine kabul ve prosedür sonrası iki ayda reflü semptomlarının varlığı olarak değerlendirildi Bulgular: Hastaların ortalama yaşı 49,3 ± 13,3 yıl idi ve semptomların süresi 6 ay ile 10 yıl arasında değişiyordu. Ameliyat öncesi medyan Eckardt skorları 9 idi ve 5 ile 12 arasında değişiyordu. Prosedür sonrası 2. ayda hastaların %96,1'i 3 veya daha düşük bir Eckardt skoruna sahipti, medyan 8 puanlık bir azalma ile (IQR = 6 – 8, p < 0.001). Hastaların %13,7'si advers olaylarla karşılaştı, bunların %3,9'u pnömomediastinum, %1,9'u mediastinit ve %1,9'u tünel içi kanama içeriyordu. Prosedür sonrası 2. ayda hastaların %17,6'sı reflü özofajiti sergiledi. Hiçbir hastada mortalite gözlenmedi. Sonuçlar: POEM, akalazya için etkili, güvenli ve minimal invaziv bir tedavi olup, semptomatik rahatlama, yaşam kalitesinde iyileşme sunan ve yüksek klinik başarı oranı ile umut verici bir terapötik seçenek olarak öne çıkmaktadır. Düşük oranda gözlenen advers olaylar yönetilebilir düzeydeydi ve mortaliteye neden olmadı.
This article aims to explore details of research, evidence, and key concepts intended for nurses and other healthcare clinicians surrounding the paradigm shift in therapeutic endoscopy relating to the third-space endoscopic procedure, peroral endoscopic myotomy. Although many medical publications detail the procedure, there are no specific guidelines for nurses to reference when caring for the patient undergoing peroral endoscopic myotomy. With scant published resources available to direct nurses distinctly in the delivery of exceptional care to patients undergoing peroral endoscopic myotomy, there is an identified need for collated information to be accessible to all nurses providing perioperative teaching and care. As peroral endoscopic myotomy continues to transpire as a mainstream or preferred standard treatment for patients who suffer from achalasia, relevant education remains to be fully understood and assessed in the nursing arena. By examining nursing considerations for patient care, indications, techniques, and advancements regarding this ever-emergent breakthrough, readers will discover guidance in comprehensive care encompassing patients undergoing the peroral endoscopic myotomy procedure.
Background and study aims Peroral endoscopic myotomy (POEM) is a minimally invasive endoscopic procedure for the treatment of achalasia and certain spastic esophageal motility disorders, delivering excellent results in experienced hands. However, this complex and technically challenging procedure requires advanced endoscopic skills. The aim of this study was to conduct a systematic review and meta-analysis of current data to evaluate the learning curve for POEM in new adopters of this technique.
Methods Electronic databases (PubMed, Embase, and Cochrane Library) from inception to November 2021 were searched for publications addressing the learning curve in POEM. Pooling was conducted by both fixed- and random-effects models. Secondary outcomes reviewed were clinical success defined by Eckardt score ≤ 3 when available and adverse events.
Results Eight studies involving 1904 patients met the inclusion criteria. In the pooled analysis, new adopters of POEM attained proficiency at a mean of 24.67 procedures (95 %CI 23.93 to 25.41). Once proficiency was achieved, the pooled total procedure time plateaued at a mean of 85.38 minutes (95 %CI 81.48 to 89.28), the pooled mean procedure time per centimeter of myotomy was 6.25 minutes (95 %CI 5.69 to 6.82), and the pooled mean length of myotomy was 11.49 cm (95 %CI 10.90 to 12.08).
Conclusions Our analysis showed that new adopters of POEM with previous advanced endoscopy experience required about 25 procedures to attain proficiency. The average time for each procedure once proficiency was attained was about 85 minutes.
