2. CONTENTS
INTRODUCTION
HISTORY
ACHALASIA CARDIA
PRINCIPLE OF POEM
DEVICES USED IN POEM
PREOP WORK UP IN POEM
OPERATIVE PROCEDURE OF POEM
POSTOP FOLLOW UP IN POEM
CONTRAINDICATIONS OF POEM
3. INTRODUCTION
POEM is an endoscopic procedure used for treatment of
achalasia
Inner circular muscle layer of lower esophageal sphincter
is cut through submucosal tunnel
This enables food & liquids to pass into stomach
4. HISTORY
Principle of endoscopic surgical myotomy was developed
in 2000 on animal models.
First endoscopic myotomy was performed on human by
H. Inoue in Tokyo, japan in 2008
5. Esophagus Anatomy
Muscular tube, 25cms long, posterior mediastinum, extending from upper
esophageal sphincter (cricopharyngeus) to cardia of stomach
C6 to T11
Parasympathetic nerve supply is mediated by vagus N,
that has synaptic connection to myenteric plexus
6. Esophagus physiology
Transfer food from mouth to stomach in a coordinated fashion.
The body of esophagus propels the bolus through relaxed lower esophageal
sphincter.
It is under vagal control via myenteric plexus (Neurotransmitter) that control
LOS
LOS is a zone of relative high pressure that prevent reflux
LOS is 3-4cms in length and has pressure of 10-25mm Hg
7. Achalasia cardia
Fail to relax
Due to loss of ganglion cells myenteric plexus
Unknow etiology
8. Achalasia clinical features
Young adults
Classical triad - dysphagia, regurgitation, weight
loss
Heartburns, postprandial choking, nocturnal
cough
9. ACHALASIA CARDIA Types
Type 1 achalasia (classical achalasia)- High integratred relaxation pressure (>15 mmHg),
No peristalsis,
Premature contraction
Type 2 achalasia (esophageal compression)- High IRP
No peristalsis,
Panesophageal pressurization
Type 3 achalasia (spastic achalasia)- High IRP
No peristalsis,
Spastic contraction
10. Achalasia diagnosis
Endoscopy- tight cardia, food residue in esophagus
Barium study- bird beak appearance
High resolution esophageal manometry- LOS doesn’t
relax properly on swallowing, no peristalsis, raised LOS
pressure
11. Achalasia treatment
Among motility disorders, achalasia well responds to treatment
Pneumatic dilatation- stretching of cardia with balloon dilation
Botulinum toxin- endoscopic injection into LOS, interfere with
cholinergic excitatory neural activity , temporary effect
Drugs- calcium channel antagonist (Sublingual Nifedipine),
transient relief of symptoms, if definite treatment is postponed
19. Overtube
• Facilitate luminal access during POEM
• Limit oropharyngeal trauma
• Length approx. 20-25cms
• Stabilize the endoscope and maintain consistent access for repeated insertion
20. Gas insufflation
• CO2 insufflation is utilized during the procedure
• Low controlled gas flow 1.2L/min is beneficial for
decrease the risk of gas dissection
• A decompression (Veress) needle should be available to
perform , if significant capnoperitoneum is present
21. Knives
• Triangle tip knife is monopolar energy device with
1.6mm triangular plate
• Three angulation at tip permit smooth sparying of
energy over wide circumferential wall.
• More efficient dissection, less bleeding
Hybrid knife for mucosal lift and dye injection
It has a central capillary within the cutting knife
Water jet
22. Electro Surgery Unit
• Deliver high frequency electrical current
to endoscopic device
• Tissue cutting, tissue coagulation
23. Hemostatic forceps
• Bleeding in submucosal space from muscular layer
• Coagulate bleeding vessels
• Monopolar and bipolar
24. Mucosal closure device
• Adequate closure of mucosal entry site to prevent
passage of esophageal content into submucosal plane,
peritoneal cavity, mediastinum.
• optimal closure device must be safe, efficient,
inexpensive, reliable and durable
Endoscopic clips
Sutures
Mucosal flap
25. PRE OPERATIVE WORK UP FOR POEM
Consent
On clear liquid diet 24hrs prior to the procedure
5 days of preoperative prophylactic nystatin swish & swallow
Pre operative prophylactic antibiotic
Single dose dexamethasone (10mg) iv preop – to prevent mucosal edema
27. Endoscopic measurement
Short overtube is used, exception to long endoscopic
myotomy
Overtube stabilises the endoscope, result in less tension at
mucostomy
Achalasia type 1,2 – short myotomy is performed
Achalasia type 3 – long myotomy
28. Saline lift and mucostomy
Site of mucosal incision – 3 to 4cms proximal to site of myotomy
Lifting solution- 1ml methylene blue + 500ml NS + adrenaline (1:1000)
Mucosal saline lift is done by using lifting solution into submucosal space
through 23G endoscopic injection needle
1.5 cm mucostomy is performed using hook or triangle tip cautery
29. Submucosal tunnelling
Endoscope is inserted through mucostomy and submucosal plane
Hydrostatic dissection can be performed instilling lifting solution
Mucosa and submucosa are separated from circular fibre using
cautery
Large bridging veins are occasionally encountered, managed by
cautery
Difficult bleeding can be controlled by direct pressure by
dissecting cap
During mucosal tunnelling care must be taken to avoid mucosal
injury from cautery and shear injury from endoscope
30. Circular myotomy
Myotomy begins at 2 to 3 cm distal to mucostomy
Division of circular muscle fibre using endocut
current by triangle tip/hook cautery
Once circular muscle fibre divided, longitudinal
muscle fibre easily visible
The plane between longitudinal and circular fibre
is followed distally with continued myotomy
Myotomy should be continued well into stomach
wall
Circular myotomy
u Myotomy begins at 2 to 3 cm distal to mucostomy
u Division of circular muscle fibre using endocut
current by triangle tip/hook cautery
u Once circular muscle fibre divided, longitudinal
muscle fibre easily visible
u The plane between longitudinal and circular fibre
is followed distally with continued myotomy
u Myotomy should be continued well into stomach
wall
31. Mucostomy closure
Once adequate dissection is achieved ,
mucostomy is closed using endoscopic clips or
endoscopic sutures
Any mucosal perforations to be closed first,
then mucostomy closure distal to proximal
Mucostomy closure
u Once adequate dissection is achieved ,
mucostomy is closed using endoscopic clips or
endoscopic sutures
u Any mucosal perforations to be closed first,
then mucostomy closure distal to proximal
32. Post op care in POEM
Before initiating oral intake , water soluble contrast
esophagogram on postop day 1
7 days of pureed diet, next normal diet
Hospital stay is 1 day
Patient can resume normal activity after 4 days
Review endoscopy, barium swallow, pH 3/4 weeks post op
5 yearly endoscopic screening due to risk of squamous cell
carcinoma
33. POEM IN PAEDIATRIC POPULATION
Chen et al. report on a series of POEM done in 27 paediatric patients. Technique
was almost identical to adults.
Due to shorter physiologic length of esophagus, shorter myotomy was performed.
19% had mucosal perforation and 19% had symptomatic GERD, which doesn’t
differ significantly from that seen with LHM.
In conclusion, myotomy is safe and effective in children as young as 3 yr old.
Due to shorter esophagus, shorter myotomy (5-7cm) may required. GERD is
concern in these patients & must be monitored closely.
34. POEM IN OBESE POPULATION
Achalasia in morbidly obese population is rare (1%
incidence)
There is not much reported experiences in treating these
patients
It will take more experience with POEM in this
population to fully understand its efficacy
35. POEM IN CHAGAS DISEASE
Esophageal dysmotility by Trypanosoma cruzi
South America
Dysphagia, regurgitation, chest pain, weight loss, megaesophagus
Esophageal manifestation of Chagas disease are significant cause of morbidity in
endemic area.
Patient with megaesophagus may require esophagectomy, but there is a clear role
for esophageal myotomy in early & late stage of disease.
But no cases of POEM have yet been published in literature, and the role of
POEM in management of Chagas achalasia has not yet been determined.
36. COMPLICATIONS OF POEM
Mucosal injuries (burns, small perforations) can occur
upto 25% cases
Full thickness perforations are very rare and can cause
serious harm to patient, if not detected early
Mucostomy dehiscence and post op bleeding are also
rare, but can be managed endoscopically
37. HELLER MYOTOMY
Cutting the muscle of lower esophagus and cardia
Successful in more than 90% cases after failed dilatation.
Major complication is Gastro-esophaeal reflux.
38. POEM VS LAP HELLER MYOTOMY
Same cost effectiveness
Same reflux rates (10-40%)
POEM
Better outcomes
Shorter hospital stay
No scar
Low blood loss
