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Peroral Endoscopic Myotomy (POEM) - UpToDate
Peroral Endoscopic Myotomy (POEM) - UpToDate
All topics are updated as new evidence becomes available and our peer review process is complete.
INTRODUCTION
Achalasia results from progressive degeneration of ganglion cells in the myenteric plexus in
the esophageal wall. It is characterized by the failure of relaxation of the lower esophageal
sphincter (LES), often accompanied by a loss of peristalsis in the distal esophagus. Treatment
of achalasia is aimed at decreasing the resting pressure in the LES to allow passage of
ingested material.
Achalasia can be treated with pneumatic dilatation, botulinum toxin injection, or surgical
myotomy. Laparoscopic Heller myotomy is the most commonly performed surgical myotomy
procedure. (See "Surgical myotomy for achalasia".)
Peroral endoscopic myotomy (POEM) is the endoscopic equivalent of surgical myotomy and
a newer technique for the management of achalasia. POEM utilizes the principles of
submucosal endoscopy to transform the submucosal layer in the esophagus and proximal
stomach into a tunnel through which esophageal and gastric myotomy are carried out using
a flexible endoscope [1]. Because POEM is performed perorally without any incisions in the
chest or abdomen, it is a form of natural orifice transluminal endoscopic surgery (NOTES).
The indications, contraindications, techniques, and outcomes of POEM are discussed in this
topic. The clinical manifestations, diagnosis, and other treatment options of achalasia are
reviewed elsewhere. (See "Achalasia: Pathogenesis, clinical manifestations, and diagnosis"
and "Overview of the treatment of achalasia" and "Surgical myotomy for achalasia".)
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PATIENT SELECTION
Although POEM was developed for achalasia, it is increasingly being used to treat other
spastic foregut disorders, such as diffuse esophageal spasm (DES) or Jackhammer
esophagus [4-9] (see 'POEM for spastic esophageal disorders' below). A detailed discussion
of spastic foregut disorders can be found in a separate topic. (See "Distal esophageal spasm
and hypercontractile esophagus".)
Additionally, the POEM procedure has been adapted to be performed in the stomach
(termed gastric or G-POEM) for the treatment of severe gastroparesis that is refractory to
medical therapy in selected patients [10,11]. (See 'POEM for gastroparesis' below and
"Treatment of gastroparesis".)
Contraindications — Patients with one of the following conditions should not undergo
POEM:
● Prior therapy that may compromise the integrity of the esophageal mucosa or lead to
submucosal fibrosis (eg, radiation, endoscopic mucosal resection, or radiofrequency
ablation)
Previous therapies for achalasia, such as pneumatic balloon dilation, botulinum toxin
injection, or surgical myotomy, are not contraindications to POEM, although in such cases
inflammatory fibrosis may be encountered during submucosal dissection. (See 'Step 2:
Creation of submucosal tunnel' below.)
POEM has been successfully performed in patients at both extremes of age. Several series
have reported the successful use of POEM in children [12-14].
PREOPERATIVE EVALUATION
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Prior to performing a POEM procedure, it is crucial to confirm that patients have the correct
diagnosis of achalasia or a spastic esophageal disorder based on the following information:
OPERATIVE MANAGEMENT
Preoperative preparation — All patients are placed on a liquid diet for one to two days prior
to a POEM procedure to ensure a clear endoscopic view and avoid aspiration during
induction of anesthesia.
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We prefer to use a high-definition therapeutic gastroscope with both a large suction channel
and a dedicated water jet channel for removing food residue in the esophageal lumen [17]. A
transparent cap is secured onto the tip of the gastroscope with tape to prevent accidental
dislodgement within the submucosal tunnel. Carbon dioxide (CO2), which is more readily
absorbed than air, should be used for insufflation to reduce the risk of mediastinal
emphysema, tension pneumoperitoneum, or pneumothorax.
POEM can be performed in the operating room or the endoscopy suite. We perform POEM in
the endoscopy suite. The patient is placed supine with the abdomen exposed. A thorough
cleansing of the esophageal lumen is performed with water or an antibiotic solution prior to
any mucosal incision. Any adherent residue present on the esophageal mucosa can be
removed using the cap or suction.
Operative technique — The POEM procedure is carried out in four consecutive steps: 1)
mucosal incision and entry into the submucosa, 2) creation of a submucosal tunnel, 3)
myotomy, and 4) closure of the mucosal incision ( figure 1) [18].
Step 1: Mucosal incision — A mucosal incision is made to allow the gastroscope to enter
the submucosal space to create the submucosal tunnel.
The location of the mucosal incision is determined by the level of the esophagogastric
junction (EGJ) and the length of the submucosal tunnel required. The length of the
submucosal tunnel required is further determined by the length of the myotomy required. In
patients with achalasia subtype I or II, a 6 to 8 cm esophageal myotomy is performed. In
patients with spastic esophageal disorders, the length of myotomy is typically longer and
determined by the proximal extent of the hypertensive contractions as measured by high-
resolution esophageal manometry and/or the level of visible spastic contractions seen
endoscopically. (See "Achalasia: Pathogenesis, clinical manifestations, and diagnosis", section
on 'High-resolution manometry'.)
In most centers, the mucosal incision, submucosal tunnel, and myotomy are created at an
anterior position (2 o'clock) of the esophageal lumen. In other centers, a posterior position (5
o'clock) is favored. Randomized trials comparing the two positions found no difference in
efficacy or adverse events with up to two-year follow-up [19,20]. A systematic review and
meta-analysis found the anterior and posterior myotomy in POEM to be comparable in
clinical success, gastroesophageal reflux disease, and adverse event rates, but posterior
myotomy required less procedure time (62 versus 82 minutes) [21]. The anterior and
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posterior positions of the esophageal lumen can be distinguished by injecting water, which
pools posteriorly with the patient supine.
Using a mixture of 0.01% epinephrine and 0.25% indigo carmine in 0.9% saline, a
submucosal bleb is first raised at a level that is 2 to 3 cm above the proximal margin of the
intended myotomy. Either a triangular tip knife or a HybridKnife can be used to make a 1.5 to
2 cm longitudinal mucosal incision using dry cut mode at 50 watts on effect 3 (ERBE).
HybridKnife has the advantage of permitting both needleless, high-pressure water jet
injection and electrosurgical dissection without accessory exchange. The gastroscope is then
maneuvered into the submucosal space after dissecting the submucosal fibers at the
mucosal incision with the knife.
The gastroscope must be properly oriented as it is advanced through the submucosal tunnel
to preserve the integrity of the mucosal layer. After myotomy, the mucosal layer becomes
the only remaining barrier between the mediastinum/peritoneum and the
esophageal/gastric lumen.
Larger blood vessels in the submucosa are coagulated using hemostatic forceps (eg,
Coagrasper in soft coagulation mode at 80 watts on effect 5, ERBE) or the HybridKnife.
The submucosal tunnel is extended until it is 2 to 3 cm beyond the EGJ, passing where the
"clasp and sling" fibers maintain the continence of the lower esophageal sphincter (LES)
( figure 2). Complete division of these "clasp and sling" fibers is essential to the success of
myotomy.
The EGJ can be located endoscopically by multiple methods, including insertion depth,
narrowing of the submucosal space and resistance of passage of the endoscope through the
EGJ followed by prompt expansion of the space at the gastric cardia, change in vasculature,
visualization of aberrant longitudinal muscle fibers at the EGJ, or injection of epinephrine or
indocyanine green (ICG) [22,23]. When the gastroscope is positioned in the lumen of the
stomach, extension of the submucosal tunnel past the EGJ can also be confirmed by
retroflexing and visualizing adequate levels of color change caused by indigo carmine in the
submucosa.
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Step 3: Myotomy — Selective myotomy of the inner circular muscle bundles is performed
starting 2 cm distal to the mucosal incision. Circular muscle bundles are individually lifted
toward the submucosal tunnel by the sharp tip of the knife and divided with spray
coagulation current at 50 watts on effect 2 (ERBE).
Selective myotomy of the inner circular muscle proximal to the LES with preservation of the
outer longitudinal esophageal muscular layer is often performed during POEM to avoid
entering the pleural space. When performed by less experienced operators, such technique
adds a "safety net" to the procedure.
However, selective myotomy is often hard to achieve because the longitudinal muscle fibers
of the esophagus are extremely thin and prone to splitting during dissection. Furthermore,
the plane that separates the circular and longitudinal muscular layers becomes difficult to
delineate beyond the esophagus.
The optimal depth of myotomy is not known; the advantages of selective inner circular
muscle versus full-thickness myotomy are only theoretical. One retrospective study
suggested that both techniques were equally effective and safe, although full-thickness
myotomy was associated with a shorter procedure time [24].
Step 4: Closure of mucosal incision — Before closure of the mucosal incision, a careful
inspection of the submucosal tunnel is performed and any bleeding is controlled. The
esophageal mucosa is then inspected, and any incidental tear (ie, mucosotomy) is closed.
Adequate LES relaxation is confirmed by a retroflexed view of the gastric cardia.
Closure of the mucosal incision can be performed with endoscopic clips [23,26] or with an
endoluminal suturing device (eg, OverStitch) [27]. When endoscopic clips are used, the initial
clip is placed at the most distal part of the incision to facilitate approximation of the incision
borders. Subsequent clips are then placed in a distal to proximal direction until the mucosal
incision is completely closed.
POSTOPERATIVE CARE
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Patient care after POEM procedures has not been standardized. Patients are typically
admitted to the hospital for overnight observation and kept nil per os and given antibiotics
and antiemetics prophylactically. Some experts obtain a water-soluble contrast esophagram
on the day after the procedure to exclude an esophageal leak [28], after which a soft diet is
allowed. Patients are advised to remain on a soft diet for 7 to 10 days before starting a
regular diet. However, due to its established safety, it is now feasible to perform POEM as an
outpatient procedure [29,30].
● In our practice, patients who undergo an uneventful procedure with secure mucosal
closure (high confidence) are discharged home after a two-hour observation in the
endoscopy unit. Patients are allowed to drink clear liquids at that time and start a soft
diet the next day.
● A small randomized trial found that routine antibiotics beyond the prophylactic dose
may not be necessary because of a very low residual infective risk [31]. In our practice,
patients are routinely prescribed antibiotics for approximately three days.
● We also prescribe daily proton pump inhibitors (PPIs). The decision on continuing or
stopping PPIs during follow-up should depend on reflux symptoms, findings during
repeat endoscopy (if performed), and/or results of pH studies.
● During subsequent clinic visits, patients are assessed for any delayed complications
and clinical response to POEM (eg, by Eckardt score) (calculator 1).
The durable clinical success rate of POEM (usually defined as an Eckardt score of ≤3) was
between 78 and 92 percent at between two and seven years [36-41]. Less than 4 percent of
patients required retreatment for achalasia [38,40]. Patient with nonspastic (type I or II)
achalasia did better than patients with spastic (type III) achalasia or other spastic esophageal
disorders [37,39,40]. (See 'POEM for spastic esophageal disorders' below.)
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In a multicenter retrospective study involving 117 pediatric patients undergoing POEM for
achalasia, clinical success was achieved in 91 (95% CI 84-95) percent of cases after a mean
follow-up of 545 days [42]. There were a total of seven adverse events, and 15 percent of
patients had gastroesophageal reflux symptoms. There was also a trend toward more
frequent clinical failure in achalasia associated with genetic disorders (40 versus 8 percent).
Comparison with surgical myotomy — The efficacy and safety of POEM has been
compared with that of laparoscopic Heller myotomy (LHM) [43]. In a randomized trial of 221
patients with idiopathic achalasia, POEM and LHM with Dor fundoplication were equally
successful in controlling symptoms (Eckardt symptom score ≤3) at two years (83 versus 82
percent). Compared with LHM, POEM was associated with a lower rate of severe adverse
events (2.7 versus 7.3 percent) but a higher rate of reflux esophagitis (57 versus 20 percent at
three months; 44 versus 29 percent at two years) [44].
In a meta-analysis of over 7000 patients in over 70 cohort studies, POEM was more effective
than LHM in relieving dysphagia [45]. Predicted probabilities for improvement in dysphagia
at 12 months were 93.5 percent for POEM and 91.0 percent for LHM and at 24 months were
92.7 percent for POEM and 90.0 percent for LHM; both differences were statistically
significant. However, POEM was associated with higher incidences of pathologic reflux by
multiple measurements (symptoms, erosive esophagitis, and abnormal pH studies) and a
slightly longer hospital stay (by one day) than LHM. Studies on LHM had significantly longer
follow-up than POEM (41.5 versus 16.2 months); longer-term data on POEM are required
before the durability of the two procedures can be directly compared.
Based on current literature, patients with achalasia should be informed that POEM and LHM
are equally effective in relieving swallowing difficulties but POEM results in more reflux and
LHM has more adverse events. Thus, the choice may depend on available local resources and
patient/surgeon preference. (See "Surgical myotomy for achalasia", section on
'Fundoplication'.)
In a retrospective cohort study of commercially insured patients who underwent either LHM,
pneumatic dilation (PD), or POEM for achalasia in the United States between July 1, 2010, and
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December 31, 2017, the use of POEM increased from 1.1 percent (95% CI 0.2-3.2) of
procedures in 2010 to 18.9 percent in 2017 (95% CI 13.6-25.3) [47]. Compared with LHM,
POEM was associated with more subsequent diagnostic testing (incidence rate ratio [IRR] 2.2,
95% CI 1.9-2.6) and reinterventions (IRR 1.9, 95% CI 1.1-3.3). When compared with PD, POEM
was associated with more subsequent diagnostic testing (IRR 1.5, 95% CI 1.3-1.8) but fewer
reinterventions (IRR 0.4, 95% CI 0.2-0.6). The total one-year health care costs were similar
between POEM and LHM, but significantly lower for PD (mean cost difference $7674; 95% CI
$657-$14,692).
POEM for recurrent achalasia — POEM has been shown to be feasible, safe, and effective in
treating patients who have failed other prior endoscopic or surgical treatment for achalasia
[48-50].
According to the International Per Oral Endoscopic Myotomy Survey (IPOEMS), 40 percent of
POEM procedures were performed in patients with prior endoscopic therapy for achalasia
[22]. Although submucosal fibrosis caused by prior botulinum toxin injection or pneumatic
dilation may render the dissection more challenging, the general consensus among the
POEM operators was that the efficacy was not compromised in such patients [22].
● One randomized trial compared POEM with PD in patients with persistent or recurrent
symptoms after LHM [53]. A total of 90 patients were included. POEM had a higher
success rate (28 of 45 patients [62.2 percent]) than PD (12 of 45 patients [26.7 percent],
p = 0.001). Reflux esophagitis was not significantly different between POEM and PD
(34.3 versus 15 percent).
POEM procedures can be repeated in patients who develop recurrent symptoms after a
previous POEM procedure, typically on the opposite side of the esophagus. In a multicenter
retrospective study of 46 patients with failed POEM, redo POEM was technically and clinically
successful in 100 and 85 percent, respectively. The average Eckardt score decreased from
4.3±2.48 to 1.64±1.67 after redo POEM [54].
In an international multicenter study that included 1826 patients who underwent POEM, 137
patients experienced one or more adverse events (prevalence of 7.5 percent) [56]. The 156
adverse events varied in severity (116 mild, 31 moderate, and 9 severe). A total of 51
inadvertent mucosotomies occurred in 2.8 percent of patients.
Mucosal tear — Inadvertent mucosal tears (mucosotomy) during POEM require prompt
closure because they represent full-thickness esophageal perforations after all other layers
of the esophageal wall have been divided. Most mucosotomies occur at the level of the LES
and cardia where the submucosal tunnel narrows. Small mucosotomies can be closed with
endoclips; larger mucosotomies have to be closed with an endoluminal suturing device (eg,
OverStitch) [57,58]. Alternatively, mucosotomies can also be closed with fibrin glue [59] or
over-the-scope clips [60]. When a mucosotomy is detected during submucosal tunneling, it
should be closed immediately, or else its size may increase rapidly.
Mediastinitis from esophageal leak is the most feared complication of POEM but is
remarkably rare (<0.1 percent of cases) [32].
Bleeding — Bleeding during submucosal tunneling is not uncommon. The risk of bleeding
can be minimized with a careful stepwise dissection to allow for visualization of individual
blood vessels. Small vessels can be prophylactically coagulated with the electrocautery knife
itself; hemostatic forceps (eg, Coagrasper) should be used to coagulate larger vessels in the
gastric cardia. If bleeding appears to originate from a vessel along the mucosal surface,
hemostasis can be achieved with gentle pressure applied with the tip of the gastroscope for
several minutes, rather than with electrocautery.
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In a large series of 428 patients, delayed bleeding occurred in 0.7 percent of patients [61].
Patients who present with hematemesis after a POEM procedure, with or without chest pain,
should undergo emergency endoscopy, during which the clips or sutures used to close the
mucosal incision must be removed and the submucosal tunnel and myotomy site inspected
for bleeding.
Gastroesophageal reflux — The most common late adverse event associated with POEM is
gastroesophageal reflux (GER). Based on objective data (endoscopic-proven erosive
esophagitis and/or abnormal pH study), the prevalence of GER after POEM varies between 20
and 57 percent, depending on studies [32].
A 2018 meta-analysis found the prevalence of GER to be higher after POEM than after LHM
with fundoplication both in terms of symptoms (19.0 percent POEM versus 8.8 percent LHM),
abnormal pH study (39 percent POEM versus 17 percent LHM), and esophagitis (28 percent
POEM versus 7.6 percent LHM) [62]. (See 'Comparison with surgical myotomy' above.)
An observational study of 183 patients published after the meta-analysis reported subjective,
objective, and severe objective GER in 38.8, 50.5, and 19.2 percent of patients, respectively, at
about two years after POEM [63]. The independent predictors for objective GER were normal
preoperative diameter of esophagus (odds ratio [OR] 3.4) and LES pressure less than 45
mmHg (OR 1.86). The independent predictors for severe objective GER were LES pressure
less than 45 mmHg (OR 6.57) and obesity (OR 5.03). Modifiable factors such as the length of
esophageal or gastric myotomy or indication of procedure had no impact on the incidence or
severity of GER.
Although it was originally developed for achalasia, POEM has been used to treat other upper
esophagogastric diseases, such as spastic esophageal disorders and gastroparesis.
POEM for spastic esophageal disorders — Spastic esophageal disorders (SEDs) are
characterized by hyperactive esophageal contractions of either abnormal propagation
(premature contraction) or extreme vigorous contraction [64]. Examples of SEDs include
spastic or type III achalasia, distal esophageal spasm (DES), hypercontractile (jackhammer)
esophagus, and hypertensive esophageal peristalsis (nutcracker esophagus). (See "Distal
esophageal spasm and hypercontractile esophagus".)
POEM has been used to treat jackhammer esophagus, DES, spastic achalasia, and nutcracker
esophagus [4-9,27,65-67]. A meta-analysis of nine studies reported a pooled success rate of
90 percent (95% CI 84-93 percent) [68]. Neither total myotomy length nor prior treatment
status had an impact on the clinical success rate.
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Myotomy of the esophageal body (where hypertensive contractions occur), in addition to the
lower esophageal sphincter (LES), may be required to treat SEDs [5,64]. Surgical myotomy of
the upper thoracic esophagus via the transabdominal approach is technically challenging
[69]. By contrast, POEM allows access to the entire esophagus, which makes it a potentially
more effective treatment for SEDs than surgical myotomy [4,5,7-9]. As an example, in a
retrospective study of spastic (type III) achalasia, 49 patients who underwent POEM had a
higher clinical response rate than 26 patients who underwent laparoscopic Heller myotomy
(98 versus 81 percent) [65]. POEM was also associated with a shorter operative time (102
versus 264 minutes), a longer myotomy (16 cm versus 8 cm), and fewer adverse events (6
versus 27 percent).
Postoperative care for G-POEM is the same as for POEM, except that a gastric emptying
study is typically performed during follow-up to assess the effect of the myotomy on gastric
emptying. (See 'Postoperative care' above.)
Outcomes of G-POEM for gastroparesis — Multiple case series showed that G-POEM is
safe, feasible, and effective in treating severe refractory gastroparesis [71-76].
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POEM for Zenker's diverticula — A variety of endoscopic techniques have been described
for the treatment of Zenker's diverticula (ZD) with clinical success rates between 56 and 100
percent and adverse events in an average of 15 percent of cases [79]. Clinical recurrence
occurs in 10.5 percent of patients, but recurrence rates up to 35 percent have been reported.
It is not possible to accurately delineate the terminal end of the diverticulum during standard
endoscopic Zenker's septotomy, and recurrence has been linked to incomplete septotomy.
(See "Zenker's diverticulum", section on 'Flexible endoscopy'.)
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● One study included 75 patients (73.3±1.2 years, female n = 33) with a mean size of ZD of
31.3±1.6 mm (10 to 89 mm) [79]. The overall technical success rate was 97.3 percent
(73/75). There were technical failures due to inability to locate the septum and failed
tunnel creation. Adverse events occurred in 6.7 percent (5/75) of cases: one bleed (mild)
conservatively managed and four perforations (one severe, three moderate). The mean
procedure time was 52.4±2.9 minutes, and the mean length of hospital stay was 1.8±0.2
days. Clinical success was achieved in 92 percent (69/75) of patients with a decrease in
mean dysphagia score from 1.96 to 0.25. At one-year follow-up, one patient reported
symptom recurrence.
● Another study that included 89 patients with ZD assessed the long-term outcomes of Z-
POEM [83]. The mean diverticulum size was 3.4 ±1.3 cm. Technical success was achieved
in 97.8 percent of patients (n = 87) with a mean procedure time of 43.8 ±19.2 minutes.
The median postprocedure hospital stay was one day. There were eight adverse events
(9 percent; three mild, five moderate). Overall, clinical success was achieved in 84
patients (94 percent). Symptom recurrence occurred in six (6.7 percent) patients during
a mean length of follow-up of 37 months (range 24 to 63 months).
POEM for other esophageal diverticula — POEM can also be utilized for the management
of esophageal diverticula other than ZD (D-POEM). Conceptually, any esophageal
diverticulum with a significant septum can be treated with POEM.
● One small study included 11 patients with an esophageal diverticulum (Zenker's 7, mid-
esophagus 1, epiphrenic 3) [82]. The mean size of the esophageal diverticula was 34.5
mm. Technical success was achieved in 10 patients (90.9 percent) with a mean
procedure time of 63.2 minutes. There were no adverse events. Clinical success was
achieved in all 10 cases with a decrease in mean dysphagia score from 2.7 to 0.1 during
a median follow-up of 145 days (interquartile range 126 to 273).
● Another study included 25 patients (Zenker’s 20, epiphrenic 5) [84]. POEM was
technically successful in all patients. At 12 months, clinical success was achieved in 86
percent of patients without any long-term adverse events.
Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Achalasia".)
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● Outcomes – The short-term success rate of POEM for achalasia, 82 to 100 percent, is
comparable to that of laparoscopic Heller myotomy and superior to that of pneumatic
dilation. Longer-term studies revealed success rates of 78 to 92 percent at two to seven
years. POEM also appears to be a viable treatment option for patients who develop
recurrent or persistent symptoms after other treatments of achalasia, such as
pneumatic dilatation, botulinum toxin injection, or surgical myotomy. (See 'Outcomes
of POEM for achalasia' above.)
● Other POEM techniques – The POEM technique has been successfully used to treat
spastic esophageal disorders (eg, spastic achalasia, distal esophageal spasm,
jackhammer esophagus, or nutcracker esophagus), severe gastroparesis refractory to
medical therapy (G-POEM), and Zenker's diverticula (Z-POEM). (See 'POEM for diseases
other than achalasia' above.)
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GRAPHICS
POEM procedure
(C, D) Myotomy
Reproduced with permission from: Dr. Haru Inoue. Image originally published in Inoue H, Minami H, Kobayashi T, et al.
Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy 2010; 42:265. Copyright © 2010 Georg Thieme
Verlag KG. All rights reserved.
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The proximal margin of the lower esophageal sphincter (LES) extends up to and a short distance
proximal to the squamocolumnar junction (not shown). The distal margin of the LES is more difficult
to define, but careful anatomic studies suggest that it is composed of elements of the gastric
musculature, the opposing clasp, and sling fibers of the gastric cardia.
Adapted from: Liebermann-Meffert D, Allgöwer M, Schmid P, Blum AL. Muscular equivalent of the lower esophageal sphincter.
Gastroenterology 1979; 76:31.
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Z-POEM technique
(C) A submucosal tunnel is created using spray coagulation and injection of saline/indigo carmine
solution via the pump. Once the septum is exposed, the septotomy is performed using an endoscopic
submucosal dissection knife with an insulated tip.
(C-E) The septotomy is extended until the longitudinal muscle fibers of the esophagus proper are
exposed (thick arrow).
Reproduced from: Brewer Gutierrez OI, Ichkhanian Y, Spadaccini M, et al. Zenker's diverticulum per-oral endoscopic myotomy
techniques: Changing paradigms. Gastroenterology 2019; 156:2134. Illustration used with the permission of Elsevier Inc. All
rights reserved.
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