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World J Gastrointest Endosc. May 16, 2015; 7(5): 496-509
Published online May 16, 2015. doi: 10.4253/wjge.v7.i5.496
Peroral endoscopic myotomy
Vivek Kumbhari, Mouen A Khashab
Vivek Kumbhari, Mouen A Khashab, Department of Medicine and Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, MD 21205, United States
Author contributions: All authors were involved in writing and critical revision of the manuscript.
Conflict-of-interest: Mouen A Khashab is a consultant for Boston Scientific and Olympus America and has received research support from Cook Medical; Vivek Kumbhari has no relevant disclosures.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Mouen A Khashab, MD, Associate Professor, Department of Medicine and Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, 1800 Orleans St, Suite 7125 B, Baltimore, MD 21205, United States. mkhasha1@jhmi.edu
Telephone: +1-443-2871960 Fax: +1-410-5020198
Received: October 6, 2014
Peer-review started: October 6, 2014
First decision: October 28, 2014
Revised: November 15, 2014
Accepted: January 18, 2015
Article in press: January 20, 2015
Published online: May 16, 2015
Processing time: 223 Days and 21.9 Hours
Abstract

Peroral endoscopic myotomy (POEM) incorporates concepts of natural orifice translumenal endoscopic surgery and achieves endoscopic myotomy by utilizing a submucosal tunnel as an operating space. Although intended for the palliation of symptoms of achalasia, there is mounting data to suggest it is also efficacious in the management of spastic esophageal disorders. The technique requires an understanding of the pathophysiology of esophageal motility disorders as well as knowledge of surgical anatomy of the foregut. POEM achieves short term response in 82% to 100% of patients with minimal risk of adverse events. In addition, it appears to be effective and safe even at the extremes of age and regardless of prior therapy undertaken. Although infrequent, the ability of the endoscopist to manage an intraprocedural adverse event is critical as failure to do so could result in significant morbidity. The major late adverse event is gastroesophageal reflux which appears to occur in 20% to 46% of patients. Research is being conducted to clarify the optimal technique for POEM and a personalized approach by measuring intraprocedural esophagogastric junction distensibility appears promising. In addition to esophageal disorders, POEM is being studied in the management of gastroparesis (gastric pyloromyotomy) with initial reports demonstrating technical feasibility. Although POEM represents a paradigm shift the management of esophageal motility disorders, the results of prospective randomized controlled trials with long-term follow up are eagerly awaited.

Keywords: Peroral endoscopic myotomy; Achalasia; Myotomy; Dysphagia

Core tip: Peroral endoscopic myotomy (POEM) is a minimally invasive, scarless approach to Heller myotomy for the palliation of symptoms of achalasia and spastic esophageal disorders. Current data demonstrates short-term success with minimal adverse events. POEM is no longer considered experimental with approximately 5000 procedures performed worldwide. In the future, a personalized approach to POEM will be undertaken with tailoring of the length of gastric myotomy based on intraprocedural physiological measurements. This will allow sufficient reduction in pressure at the lower esophageal sphincter for adequate relief of symptoms but also minimize gastroesophageal reflux.