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Treating Achalasia with the Minimally Invasive POEM Procedure
Achalasia is a condition that prevents the lower esophageal sphincter (LES) from properly relaxing. This leads to difficulty swallowing and an inability to comfortably eat and drink. Patients with achalasia also commonly experience regurgitation, difficulty belching, substernal chest pain, heartburn, and weight loss. Nearly 3,000 people in the United States are affected annually.
The standard operation for achalasia treatment (laparoscopic Heller myotomy) requires multiple incisions through a patient’s abdominal wall. A new procedure — POEM (Perpral Endoscopic Myotomy) — allows creation of the myotomy without any abdominal incisions. Many experts in esophageal surgery are now advocating this approach as the preferred approach for achalasia management.
Achalasia is typically diagnosed during an evaluation for dysphagia. A barium esophagram will show a dilated esophagus and a “bird’s beak” narrowing of the distal esophagus. This represents a narrow column of barium flowing through a tight lower esophageal sphincter. Esophageal manometry is the gold standard diagnostic test. The classic findings are:
An EGD is also obtained to rule out pseudoachalasia, which can occur if a malignant lesion in the distal esophagus causes distal esophageal narrowing and proximal esophageal dilation (which may look similar to achalasia on an esophagram).
General treatment approaches for achalasia
The goal of treatment is to decrease the resting pressure of the LES so that liquid and foods may pass unimpeded into the stomach. Mechanical disruption of the LES, either via surgical myotomy or endoscopic pneumatic dilation, is the preferred treatment approach. Biochemical relaxation (via medications such as oral nitrates, calcium channel blockers, or endoscopic botox injections) is also an option, although it is less effective and typically reserved for patients who cannot undergo mechanical LES disruption (e.g. those who cannot tolerate general anesthesia). Among the two options for mechanical LES disruption, most surgeons recommend surgical myotomy as the first-line treatment. Pneumatic dilation, while initially effective, is felt to have lower long-term success rates as nearly one-third of patients will relapse within five years and require surgical myotomy.
Traditional surgical options for achalasia
Laparoscopic Heller myotomy has been the gold standard surgical approach for the past two decades. This operation involves multiple small abdominal wall incisions to access the abdomen and allow the surgeon to perform a myotomy (cutting the muscle fibers of the distal esophagus and proximal stomach thereby dividing the LES). A partial stomach fundoplication (either a Toupet or Dor) is typically added to decrease the likelihood of symptomatic GERD.
Within the past decade, robot-assisted Heller myotomy has emerged as an alternative approach that appears to achieve comparable outcomes. Similar to a laparoscopic Heller myotomy, it requires multiple abdominal incisions to access the abdominal cavity.
What is Peroral Endoscopic Myotomy (POEM)?
POEM represents a new paradigm for achalasia treatment. It combines the minimally invasive benefit of endoscopy with the durability of a surgical myotomy. First performed in 2008, POEM uses a flexible upper endoscope to create a small incision into the mucosa of the esophagus. The endoscope is then tunneled into the esophageal wall and an endoscopic myotomy is performed (analogous to one performed during a traditional Heller myotomy). Once complete, the esophageal mucosal incision is closed using clips. POEM typically takes two to three hours to perform and requires general anesthesia. Follow-up includes an upper GI to assess swallowing the morning after surgery. A full liquid diet is initiated which typically lasts two weeks after which time the patient’s diet is slowly advanced. Patients are typically seen in clinic two and six weeks post procedure.
Who is a candidate for POEM?
Most patients with achalasia are candidates for POEM. Relative contra-indications include patients with prior radiation to the mediastinum, prior endoscopic treatment (such as endomucosal resection or musosal ablation), or those who are poor surgical candidates in general (severe pulmonary disease, coagulopathy, portal hypertension).
What are the advantages of POEM?
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