Minimally invasive endoscopic procedure can be life-changing for some patients.
Esophageal achalasia is rare, affecting one to two people per 100,000 globally, but these numbers have grown in recent years with the introduction of high-resolution manometry and other advanced diagnostics. Peroral endoscopic myotomy (POEM) has proven safe and effective in the treatment of achalasia and has shown promising outcomes for other esophageal motility disorders.
Vanderbilt Digestive Disease Center is a destination center for the treatment of achalasia and began performing POEM in 2018. Vanderbilt researchers are conducting ongoing investigations testing the safety and efficacy of POEM compared with other surgical techniques.
“Not all centers offer POEM because it requires a multidisciplinary approach, specialized advanced endoscopic training and a high degree of technical precision.”
“POEM is a less invasive alternative to traditional surgery for patients not responding to conventional endoscopic and medical therapies,” said Julianna Yang, M.D., an assistant professor of gastroenterology at Vanderbilt University Medical Center. “Not all centers offer POEM because it requires a multidisciplinary approach, specialized advanced endoscopic training and a high degree of technical precision.”
Advantages of POEM
Achalasia is characterized by loss of peristalsis and failed relaxation of the lower esophageal sphincter (LES), resulting in a wide array of debilitating symptoms. Standard treatments include pneumatic balloon dilation, botulinum toxin injection or dividing the LES surgically using techniques such as open or laparoscopic Heller myotomy (LHM).
Heller myotomy often requires thoracotomy or thoracoscopy to reach the esophagus and is limited by the length of esophagus that can be reached. The advantage of POEM is that it allows full visualization of the entire esophagus, said Chetan Aher, M.D., an assistant professor of surgery at Vanderbilt. “For instance, in type III, or spastic, achalasia some data says that the longer the myotomy, the better the outcome; POEM offers the ability to perform a longer myotomy.”
POEM has shown a favorable safety and efficacy profile, with most adverse effects mild to moderate; fewer than 1 percent were severe. Today, POEM is considered the endoscopic equivalent of LHM, with clinical success between 93 and 98 percent, and is used as first-line therapy in expert centers.
POEM procedures must be performed under general anesthesia with paralytics and endotracheal intubation, and the patient will typically remain in the hospital 24 hours for observation. “POEM is a little better for recovery because there are no incisions,” Aher said. “However, it’s still surgery and has to be treated with the same level of detail and respect.”
Rescue and Difficult Cases
Persistent or recurrent symptoms can occur in up to 20 percent of LHM cases. This has been attributed to inadequate myotomy, Yang explains, which is circumvented in POEM via direct endoscopic visualization. In the subset of patients with recurrent symptoms, POEM has been shown to have promising short-term outcomes after prior failed LHM, with a success rate around 98 percent.
In elderly patients with significant comorbidities, POEM offers a minimally invasive alternative to surgical interventions. Although achalasia is a rare disease in children, studies have shown that POEM can be performed successfully in infants as young as 11 months.
Yang says the most challenging long-term complication of POEM is gastroesophageal reflux disease. “Post-POEM, we initially prescribe acid suppression medication for all patients. This is subsequently individualized to each patient’s symptoms.”
Treating Complex Disorders
As POEM has gained wider acceptance for treating achalasia, it has been expanded to treat other complex esophageal motility disorders, including esophageal spasms, jackhammer esophagus and esophagogastric junction outflow.
“Since we know we’re not curing this condition, we want to offer patients all their options.”
POEM is not for everyone with achalasia, Aher cautions. “Since we know we’re not curing this condition, we want to offer patients all their options and give them a preview of what the next 10-20 years will look like so they can make an informed decision.”