Per-oral endoscopic myotomy (POEM) for achalasia: techniques and outcomes

Achalasia is a rare esophageal motility disorder characterized by aperistalsis of the esophagus, confirmed by manometry with impaired relaxation of the lower esophageal sphincter (LES). Surgical treatments include laparoscopic Heller myotomy (LHM) or robotic -assisted Heller myotomy (RHM) combined with fundoplication, per -oral endoscopic myotomy (POEM), and esophagectomy. POEM was first introduced in 1980 by Ortega and over the course of the next 30 years important modifications were made to his technique. POEM is now considered an alternative to LHM, particularly in patients with type III achalasia treated at high -volume centers. POEM is less invasive than laparoscopic myotomy and allows the surgeon to perform a longer myotomy, which may improve clinical response in patients with type III achalasia. We describe our technique of POEM in this article. First, we create a mucosotomy to expose the submucosal layer of the esophagus. We then create a submucosal tunnel, which gives access to the inner circular muscles of the esophagus and perform the myotomy across the LES. Finally, we close the mucosotomy. Most patients experience few postoperative complications, but gastroesophageal reflux is the most common postoperative complication and the main shortcoming of POEM. POEM yields excellent symptom palliation in most patients and has been demonstrated to be as safe as laparoscopic myotomy.