Peroral Endoscopic Myotomy (POEM)

Peroral Endoscopic Myotomy (POEM) is an endoscopic procedure used to treat achalasia and other esophageal disorders. This procedure treats swallowing disorders often caused by muscle problems or spasms in the esophagus. The esophageal muscles and lower esophagus sphincter may not fully relax making it hard to swallow and for food to pass through into the stomach.

POEM offers similar outcomes as surgery, but with the added benefit of not having to make a cut on the outside of the body. The advanced endoscopists who perform the POEM procedure, collaborate with specialists in our Gastrointestinal Motility Program to ensure accurate diagnosis and explore all treatment options to provide the best care to patients.

Conditions treated by POEM

POEM can be used to treat esophageal motility disorders (EMDs) that make swallowing difficult, including:

• Achalasia
• Distal esophageal spasm (DES)
• Esophagogastric (EG) junction outflow obstruction
• Jackhammer esophagus (hypercontractible esophagus)
• Nutcracker esophagus (hypertensive esophageal peristalsis)
• Zenker's diverticulum

POEM is not recommended for certain patients. People with severe liver disease, blood clotting disorders, severe bullous lung disease, or severe esophagitis (an inflammatory disorder of the esophagus) may not be candidates for the procedure.

How does POEM treat Achalasia?

Achalasia, a rare disorder, affects swallowing by limiting the movement (motility) of the esophagus and the ability of the sphincter valve (bundle of muscles) between the esophagus and stomach to relax. This makes it very difficult to swallow.

One of the most effective therapies for achalasia is to relax the lower esophageal sphincter (LES), by doing a POEM procedure where a small cut is made in the sphincter muscle so that food can pass from the esophagus to the stomach. 

POEM can be used in patients who have previously received other treatments for achalasia, including balloon dilation, Botox injections, or a Heller myotomy. It is safe for patients of all ages, including children and older adults.

Preparing for POEM

Before your procedure, you will need to follow specific preparation instructions. Your doctor will discuss them with you in detail. Preparation instructions are as follows:

• Maintain a liquid diet for two days prior to the procedure.
• No eating or drinking 12 hours prior to your procedure.
• Tell your doctors if you have any allergies.
• Speak to your doctor about which prescription medication you can take.

On the day of the procedure, arrive two hours before your POEM procedure start time. When you arrive, you will register and give your medical history.

During POEM

During a POEM procedure, a highly trained endoscopist inserts a flexible tube, or endoscope, through the mouth into the esophagus. Using special techniques, the scope can move through of the esophagus through a tunnel which the endoscopist creates in the wall of the esophagus to reach the lower esophageal sphincter. A cut, is then performed of the sphincter muscle and the tunnel is then closed with clips or sutures placed through the scope before the scope is gently removed through the mouth. After the procedure, patients may have to drink a barium solution and have X-rays taken of their esophagus to ensure they can swallow normally. Patients typically can go home the day after the procedure.

What to expect

1. We will insert an IV into your vein in order to administer fluids, anesthesia and antibiotics.
2. Your endoscopist will pass the endoscope through your mouth and into the esophagus where the therapy will be applied.
3. Your doctor observes the images on a nearby monitor.
4. There will not be any incisions or cuts outside your gastrointestinal tract.
5. We make an initial incision in the internal lining of the esophagus. This allows the endoscope to enter within the wall of the esophagus, to access exposed muscle.
6. We make a small cut in the inner layer of the muscle near the lower esophageal sphincter.
7. At the end of the procedure, we close the esophageal incision with standard endoscopic clips.

After you recover from the effects of the anesthesia, your doctor will discuss with you the results of the procedure and the next steps. Patients stay overnight at the hospital after POEM for further monitoring.