November 20

Exploring Third Space Peroral Endoscopic Myotomy (POEM) for Achalasia: Benefits, Risks, and Recovery

Navigating through the complexities of achalasia becomes significantly smoother with the advent of Third Space Peroral Endoscopic Myotomy (POEM). This game-changer is revolutionizing the gastroenterology world. Embracing advanced technology and non-invasive procedures, POEM provides hope for those with this rare and complex esophageal condition. Join us as we delve into the potential benefits, inherent risks, and what to anticipate during recovery from a POEM procedure. Though relatively novel in the gastroenterological arena of treatments, POEM holds exciting promises - are you ready to explore them?

Third space Peroral Endoscopic Myotomy (POEM) is an effective and minimally invasive treatment option for achalasia. It involves accessing the submucosal layer of the gastrointestinal tract to perform myotomy, which helps to relieve symptoms such as difficulty swallowing, regurgitation, and chest pain. POEM has shown positive results in improving patients' quality of life with achalasia. However, it is essential to consult with a renowned gastroenterologist specialized in POEM procedures to determine if it is suitable for individual cases.

Understanding Peroral Endoscopic Myotomy (POEM)

Peroral endoscopic myotomy (POEM) has emerged as a minimally invasive procedure to treat esophageal motility disorders such as achalasia. Unlike traditional surgical approaches that require external incisions, POEM is performed entirely through the mouth using an endoscope. This innovative technique allows for precise and targeted intervention, offering several benefits to patients.

POEM involves accessing the esophagus by creating a submucosal tunnel through the inner lining of the esophagus. This tunnel provides access to the muscles responsible for causing swallowing difficulties or spasms characteristic of conditions like achalasia. By precisely cutting these muscles, POEM aims to alleviate symptoms and improve overall esophageal function.

Think of it like navigating a maze inside the body, with the endoscope acting as your guide and tool. The surgeon skillfully maneuvers through the esophageal layers, reaching the target muscles with precision.

This technique has gained popularity due to its high success rates and minimal invasiveness compared to traditional open surgery. 

The key benefits of POEM include reduced pain, shorter hospital stays, quicker recovery times, and improved cosmetic outcomes since no external scarring occurs.

  • A study from 2019 revealed that the success rate of POEM for treating achalasia is approximately 92%, making it a highly effective treatment option.

  • According to the World Gastroenterology Organization, among patients who had undergone POEM, less than 0.5% reported severe complications.

  • A Japanese multicentric study in 2020 indicated that POEM's therapeutic effect can last up to five years in almost 96% of achalasia patients following the procedure.

Peroral endoscopic myotomy (POEM) is a minimally invasive procedure that treats esophageal motility disorders, such as achalasia. Unlike traditional surgery, POEM is performed entirely through the mouth using an endoscope. This innovative technique offers several benefits to patients, including reduced pain, shorter hospital stays, quicker recovery times, and improved cosmetic outcomes with no external scarring. Compared to laparoscopic Heller myotomy (LHM), another surgical treatment option for achalasia, POEM is less invasive, causes less post-operative discomfort, and has a faster recovery time. The key takeaway is that POEM is an effective and patient-friendly alternative to traditional surgical approaches for esophageal motility disorders. Furthermore, understanding the device used during the procedure will provide a comprehensive POEM overview.

Device Used During the Procedure

The primary instrument utilized in POEM is an endoscope—specifically, a flexible tube with a light and camera attached to its tip. This endoscope allows gastroenterologists to visualize the internal structures of the esophagus in real time and guide their movements during the procedure. The camera provides high-definition images, ensuring precise visualization throughout the intricate process.

In addition to visualization, specialized tools known as electrosurgical dissectors are inserted through auxiliary channels in the endoscope. These tools enable controlled cutting of the esophageal muscles or tissues while minimizing damage to surrounding areas.

By combining advanced technology with skilled surgical techniques, POEM offers an effective means to treat achalasia and other esophageal motility disorders. A thorough understanding of these processes can help patients make informed decisions and approach their treatment journey with confidence.

Operational Process of POEM

To better understand the operational process of Peroral Endoscopic Myotomy (POEM), let's dive into the intricate details. This minimally invasive endoscopic procedure is primarily used to treat achalasia. This disorder impairs the ability of the esophagus to move food into the stomach. Here's a step-by-step breakdown of how POEM is typically performed:

  1. Anesthesia and Preparation: The patient is placed under general anesthesia to ensure they are comfortable and unaware during the procedure. Once anesthesia takes effect, the gastroenterologist inserts an endoscope through the mouth and into the esophagus.

  2. Creating a Submucosal Tunnel: After entering the esophagus, the gastroenterologist carefully makes a small incision in the inner lining of the esophagus and inserts a specialized instrument called an endoscope. A submucosal tunnel is then created by advancing through layers of tissue until reaching the muscle layer. This process aims to create space for subsequent myotomy.

  3. Myotomy: Myotomy refers to the surgical division of muscle fibers to improve swallowing function. Using specialized instruments passed through the endoscope, the gastroenterologist performs a myotomy by cutting specific muscles in the lower esophageal sphincter (LES) region. It is essential to maintain precise control over this procedure to avoid any perforation or injury to surrounding structures.

  4. Closure of Incision: Once the myotomy is complete, the mucosal entry made during the procedure are meticulously closed using clips or sutures.

  5. Post-Operative Care: Following completion of these steps, patients are closely monitored in a recovery area before being transferred to their hospital room. In most cases, patients can resume a liquid diet within a few hours or by next day and gradually transition to a soft diet over the next few days. Majority of the patients leave the hospital the very next day following this procedure.

It's important to note that while this overview provides a general understanding of the POEM procedure, each patient's case is unique, and variations may occur depending on the endoscopist’s technique and the specific requirements of the individual.

Now that we have explored the operational process of POEM let's shift our focus to evaluations and patient selection for this innovative treatment option.

POEM: Evaluations & Patient Selection

When considering Oral Endoscopic Myotomy (POEM) as a potential treatment option for achalasia, several evaluations and assessments are conducted to determine patient suitability. Key factors taken into consideration include:

Symptoms: Patients with achalasia typically experience difficulty swallowing, regurgitation, chest pain or discomfort, and weight loss. A thorough evaluation of these symptoms helps identify whether POEM is appropriate for their condition. Lot of times the correct diagnosis of this condition gets delayed by several months to even few years since it is a rare disease and commonly mistaken for just acid reflux. 

Diagnostic Testing: Various diagnostic tests are utilized to confirm achalasia diagnosis and evaluate esophageal function. These may include endoscopy, manometry (which measures muscle contractions and relaxation of muscles and  in the esophagus) and barium swallow studies.

Once a patient is identified as a potential candidate for POEM based on their symptoms and diagnostic results,

Physical Condition: The overall health and physical condition of the patient play a crucial role in determining their eligibility for surgery. Factors such as heart health, underlying medical conditions, and previous surgeries are thoroughly evaluated.

Shared Decision-Making: The decision to proceed with POEM involves a collaborative approach between the patient and their gastroenterologist. A comprehensive discussion is held to weigh the potential benefits, risks, and alternatives to surgery.

By considering all these factors, healthcare providers can ensure that patients who undergo POEM are likely to experience positive outcomes while minimizing potential risks.

Recovery and Post-Operative Care

After undergoing a third space peroral endoscopic myotomy (POEM), proper recovery and post-operative care are vital for achieving optimal outcomes. While the procedure may be minimally invasive, it requires careful attention to ensure a smooth recovery process.

After completing the POEM procedure, patients are typically monitored in a recovery area for several hours. This allows medical professionals to closely observe their condition and ensure there are no immediate complications. During this time, patients may experience some discomfort or soreness in the throat or chest, which is normal and can be managed with pain medication prescribed by their healthcare provider.

It's important to note that everyone's recovery journey will differ slightly depending on various factors such as overall health, individual healing ability, and the extent of the myotomy performed. Generally, patients can expect a gradual improvement in symptoms over time.

In terms of diet, a specific post-operative care plan will be provided by the healthcare team. Initially, patients often start with a liquid diet and then progress to soft foods before reintroducing regular solid foods. It's essential to follow these dietary guidelines strictly to avoid any unnecessary strain.

It is also vital to attend all scheduled follow-up appointments to monitor progress and address any concerns that may arise.

Recovery from a POEM procedure involves more than just physical healing; it also includes psychological well-being. Acknowledging that each individual's emotional journey is unique, it's essential for patients to seek support from loved ones or consider joining support groups where they can connect with others who have undergone similar procedures.

Think of your recovery as an immersive experience where you nurture your physical and emotional well-being. Patients must prioritize self-care and follow the recommended aftercare instructions diligently.

Ultimately, patience is key during the recovery process. It may take few days before clients can resume their normal activities fully. By staying committed to proper post-operative care and following the advice of medical professionals, patients can significantly enhance their recovery and improve their long-term outcomes.

Risks & Long-Term Outcomes of POEM

While peroral endoscopic myotomy (POEM) has revolutionized the treatment of achalasia, it's essential to acknowledge the potential risks and long-term outcomes associated with this procedure. Understanding these aspects provides patients with realistic expectations and allows for informed decision-making.

One potential risk involved in POEM is the occurrence of intraoperative mucosal injury. While rare, this can happen during the procedure due to inadvertent tears or perforations in the esophageal wall. However, experienced surgeons who specialize in POEM are typically well-equipped to handle such situations promptly to minimize any adverse effects.

Another factor that can impact long-term outcomes is post-POEM gastroesophageal reflux disease (GERD). Research suggests a direct correlation between LES disruption during POEM and subsequent GERD development. However, it's important to remember that not all patients will experience GERD following the procedure, and reflux symptoms are easily managed by acid reduction medication. 

It's worth noting that the vast majority of patients who undergo POEM experience significant symptom improvement and enhanced quality of life. The procedure has demonstrated long-term success rates, with studies showing sustained improvements in swallowing function and reduced achalasia-related symptoms.

It is crucial to have an open and honest discussion with your healthcare provider regarding the potential risks associated with POEM. They will assess your circumstances, evaluate the risk factors, and guide you through the decision-making process.

Potential Complications and After-Effects of Third Space Peroral Endoscopic Myotomy

Before undergoing any medical procedure, it's essential to be aware of the potential complications and after-effects that may arise. Although Peroral Endoscopic Myotomy (POEM) is generally considered a very safe and effective treatment option for achalasia, it's important to understand the possible risks involved. Let's explore potential complications that can occur during or after a POEM procedure.

One of the primary complications associated with POEM is gastroesophageal reflux disease (GERD). As the lower esophageal sphincter is partially opened during the procedure to relieve symptoms of achalasia, there is an increased risk of gastric acid reflux into the esophagus. This may result in symptoms such as heartburn, regurgitation, and discomfort. Some patients may require ongoing management with medication for acid reflux and very rarely one might need some form of stomach wrap (fundoplication) for this issue.

Other potential complications include bleeding, infection, perforation of the esophagus or stomach lining, and pneumothorax (the presence of air in the space between the lungs and chest wall). However, it's important to note that these complications are relatively rare and occur in a small percentage of cases.

While these complications are worth considering, it's crucial to balance them against the potential benefits of POEM in treating achalasia. Achalasia itself can significantly impair an individual's quality of life due to difficulties in swallowing and other related symptoms. By undergoing POEM, many patients experience significant improvement in their ability to eat and maintain a healthy weight, as well as relief from chest pain and regurgitation. It's important to discuss these benefits with your healthcare provider and weigh them against the potential risks.

Furthermore, recovery from a POEM procedure can vary from person to person. In contrast, others may require more time for full recovery. It is crucial to follow the post-operative instructions provided by your healthcare team. These instructions may include dietary restrictions, pain management strategies, and gradually resuming normal activities.

While there are potential complications associated with POEM for achalasia, it can be a life-changing intervention for many individuals. By understanding these risks and closely following the guidance of your healthcare provider throughout the recovery process, you can increase the chances of a successful outcome. If you have any concerns or questions about POEM or its potential complications, it's always best to consult your healthcare provider for personalized advice.

Why Choose Manjakkollai P Veerabagu, MD, AGAF “Dr. Veera” ?

Dr. Veerabagu is one of the top gastroenterologists in the United States, with over 25 years of experience in clinical and academic settings. He is committed to providing high-quality treatments for patients suffering from digestive diseases.

His practice covers a comprehensive array of treatment plans for digestive disorders. He specializes in several advanced complex gastroenterological procedures, including Non-Surgical Weight Loss Procedures, Endoscopic ultrasound (EUS), Third Space Endoscopy, EMR & ESD, Advanced ERCP and Spyglass, and Advanced Complex Gastroenterological Procedures. 

His practice accepts patients from other physician referrals ONLY.

HAVE YOUR MEDICAL PROVIDER send your referrals VIA FAX (864) 222-1303 OR EPIC EMR. 


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