Peroral Endoscopic Myotomy: Procedure, Benefits, Risks, Recovery and Alternatives

Peroral Endoscopic Myotomy (POEM) has emerged as a transformative option in the management of esophageal motility disorders, especially achalasia. This minimally invasive endoscopic procedure offers new hope for patients struggling with swallowing difficulties, chest pain, and regurgitation. In this article, we delve deeply into the POEM technique, its benefits, potential risks, what to expect during recovery, and how it compares with other available treatments.

Peroral Endoscopic Myotomy: The Procedure

POEM is a cutting-edge, incisionless endoscopic procedure designed to treat esophageal motility disorders by performing a myotomy (cutting of the muscle) within the esophageal wall. It is performed entirely through the mouth, eliminating the need for external incisions, which contributes to its minimally invasive nature and rapid recovery profile.

Step	Description	Purpose	Source(s)
Preparation	Fasting, anesthesia, patient positioning	Safety and visualization	1 4 8
Mucosal Entry	Small incision made in esophageal lining	Access submucosal space	1 4
Submucosal Tunnel	Creation of tunnel in submucosal layer	Expose circular muscle layer	1 4
Myotomy	Selective cutting of muscle fibers	Relieve esophageal obstruction	1 4 6
Closure	Sealing of entry with endoscopic clips	Prevent leaks and infection	1 4

Table 1: Main Steps of the POEM Procedure

Overview of the POEM Technique

POEM is performed under general anesthesia. The endoscopist inserts a flexible endoscope through the patient’s mouth and into the esophagus. A small incision (usually 1.5–2 cm) is made in the mucosal lining, typically on the anterior or posterior esophageal wall, to access the submucosal layer 1 4 5.

Creating the Submucosal Tunnel

The submucosal tunnel is gently created to separate the mucosal layer from the muscular layer. This tunnel provides space and visibility, allowing the endoscopist to reach the lower esophageal sphincter (LES) and the upper portion of the stomach 1 4.

Performing the Myotomy

The endoscopist then selectively cuts the inner circular muscle fibers of the esophagus (and sometimes the lower esophageal sphincter), while usually leaving the outer longitudinal muscle fibers intact, although full-thickness myotomy can also be performed 1 4 16. The length of the myotomy typically ranges from 6 to 10 cm, depending on the extent of the disease 1 4 8.

Closure and Final Steps

After the myotomy, the mucosal entry point is closed with endoscopic clips to minimize the risk of leaks or infection 1 4. The entire procedure generally takes between 60 and 130 minutes, with experience and technique influencing duration 1 3 5.

Variations and Innovations

• Anterior vs. Posterior Myotomy: Both approaches are effective, with similar safety and efficacy profiles, though posterior myotomy may be faster 5.
• POEM + Fundoplication: Newer techniques add an endoscopic fundoplication to reduce reflux risk, but these are still being studied 2.
• Learning Curve: Mastery of the POEM technique usually requires significant experience; complication rates decrease notably after approximately 20–100 cases, depending on the metric 1 3.

Benefits and Effectiveness of Peroral Endoscopic Myotomy

POEM offers a blend of high effectiveness and rapid recovery, cementing its role as a first-line therapy in many centers for achalasia and related disorders.

Benefit	Description	Outcome/Metric	Source(s)
Clinical Success	High rates of symptom relief	94–98% success (Eckardt ≤3)	6 8 9 10
Minimally Invasive	No external incisions, less pain	Faster recovery, less analgesia	4 8 15
Comparable to LHM	Similar results to laparoscopic surgery	Same efficacy, less pain	7 10 15
Broad Eligibility	Works for various achalasia subtypes	Effective in prior treatment cases	14 17

Table 2: Benefits and Effectiveness Metrics for POEM

High Clinical Success

Multiple large studies and meta-analyses have shown that POEM achieves outstanding symptom relief in 94–98% of patients, as measured by the Eckardt score (a standardized symptom assessment scale). The mean score typically drops from 6–7 pre-procedure to 1 or less post-procedure, indicating near-complete resolution of dysphagia and related symptoms 6 7 8 9 10.

Minimally Invasive and Rapid Recovery

Because POEM is performed entirely through the mouth, it avoids any external incisions. This results in:

• Less postoperative pain
• Lower reliance on pain medications
• Quicker return to regular activities (2–4 days vs. about a week for surgery) 8 15

Comparable Efficacy to Laparoscopic Heller Myotomy (LHM)

POEM matches the gold standard surgical approach, LHM, in terms of symptom relief, reduction in esophageal pressures, and overall safety. Studies show no significant differences in postoperative dysphagia, pain, length of hospital stay, or adverse events 7 10 15.

Applicability Across Patient Groups

POEM is effective for a wide range of patients, including those with previous failed treatments (either endoscopic or surgical), advanced disease, or anatomical challenges 14 17. It is also being explored as a primary treatment in children and those with spastic esophageal disorders.

Risks and Side Effects of Peroral Endoscopic Myotomy

While POEM is generally safe, like any intervention, it carries potential risks and side effects. Understanding these is critical for informed decision-making.

Risk	Frequency/Severity	Notable Details	Source(s)
Minor Adverse Events	6–10% (mostly mild/moderate)	Emphysema, capnoperitoneum, fever	1 11 12
Major Adverse Events	0.5–3% (rare, serious)	Bleeding, mediastinal leak, ICU stay	11 12
GERD/Reflux	Up to 54% (objective, <25% symptomatic)	Managed with PPIs, no fundoplication	8 9 13
Technical Complications	Learning curve dependent	Mucosotomy, prolonged procedure	1 3 11

Table 3: Key Risks and Side Effects Associated with POEM

Minor and Major Adverse Events

Most adverse events are mild, such as minor bleeding, subcutaneous emphysema, or capnoperitoneum, and are typically managed conservatively or with minor interventions 1 11. Major adverse events—like delayed mucosal barrier failure, significant bleeding, or pneumothorax—are rare (0.5–3%) and usually occur in early practice or challenging cases 11 12.

• Mucosotomy (inadvertent mucosal tear): Occurs in 2–3% of cases, most often during the learning curve, and is usually repaired intraoperatively with clips 1 11.
• Severe complications: ICU admissions or life-threatening events are exceedingly rare (<1%), with no surgical conversions or 30-day mortality reported in large series 12.

Risk of Gastroesophageal Reflux Disease (GERD)

POEM does not include an antireflux procedure, so GERD is a notable side effect:

• Objective evidence of reflux (pH monitoring or endoscopy): up to 54%
• Symptomatic GERD: 8–25%
• Esophagitis: 13–27%
• Most cases are mild and managed effectively with proton-pump inhibitors (PPIs) 8 9 13

Technical and Learning Curve-Related Risks

The risk of complications decreases as endoscopists gain experience. Adverse events and procedure times drop significantly after 20–100 cases 1 3. Factors increasing risk include complex anatomy (e.g., sigmoid esophagus), less experienced operators, and certain equipment or techniques 1 3 11 12.

Recovery and Aftercare of Peroral Endoscopic Myotomy

The recovery process after POEM is typically smooth, with most patients experiencing rapid improvement and minimal discomfort.

Aspect	Typical Outcome	Timeline/Details	Source(s)
Hospital Stay	Short duration	1–4 days	8 15
Diet	Gradual advancement	Clear liquids to solids	4 8
Symptom Relief	Rapid improvement	Within days	8 9
Follow-up	Endoscopy, manometry, symptom check	1–12 months post-procedure	8 9 14

Table 4: Recovery and Aftercare Milestones for POEM

Hospitalization and Early Recovery

• Hospital Stay: Most patients are discharged within 1–4 days following the procedure 8 15.
• Pain and Activity: Minimal postoperative pain; return to daily activities within 2–4 days 8 15.
• Diet Progression: Patients start with clear liquids, advancing gradually to a regular diet over several days 4 8.

Monitoring and Follow-up

Patients are monitored for:

• Symptom recurrence (using the Eckardt score)
• Signs of infection or leak (rare)
• Development of reflux symptoms

Routine follow-up assessments include endoscopy, pH monitoring, and manometry at 3, 6, and 12 months 8 9 14.

Long-Term Aftercare

• Reflux Management: Symptomatic reflux, if present, is managed with PPIs 8 9.
• Activity Restrictions: Few, if any, restrictions after the initial recovery period.
• Re-intervention: Rarely required; if symptoms recur, options include repeat POEM or alternative therapies 14 17.

Alternatives of Peroral Endoscopic Myotomy

While POEM is highly effective, several alternative treatments are available, each with its own advantages and limitations.

Alternative	Description	Pros/Cons	Source(s)
Laparoscopic Heller Myotomy (LHM)	Minimally invasive surgery with fundoplication	Similar efficacy, includes antireflux but more invasive	7 10 15
Pneumatic Dilation	Endoscopic stretching of LES	Less invasive, higher recurrence	17
Botulinum Toxin Injection	Injection to relax LES	Temporary, for high-risk patients	4
POEM+Fundoplication	POEM with endoscopic antireflux wrap	Reduces GERD, experimental	2
Medical Therapy	Nitrates, calcium channel blockers	Least effective, for select cases	4

Table 5: Key Alternatives to POEM

Laparoscopic Heller Myotomy (LHM)

The traditional gold standard, LHM surgically divides the LES muscle via small abdominal incisions and adds a fundoplication to prevent reflux. It offers similar efficacy to POEM but with a longer recovery and more postoperative pain 7 10 15.

Pneumatic Dilation

This endoscopic procedure stretches the LES using a balloon. While less invasive, it carries a higher recurrence rate, may require repeat procedures, and has a risk of esophageal perforation 17.

Botulinum Toxin Injection

Botox injections can temporarily relax the LES but provide only short-term relief. It is generally reserved for frail or elderly patients who cannot undergo more invasive procedures 4.

POEM + Fundoplication and Emerging Techniques

Newer approaches combine POEM with endoscopic fundoplication (POEM+F) to reduce reflux rates, but these are still investigational and not yet widely available 2.

Medical Therapy

Pharmacologic options (nitrates, calcium channel blockers) are the least effective and used only in select cases where other interventions are not possible 4.

Conclusion

Peroral Endoscopic Myotomy has revolutionized the treatment landscape for esophageal motility disorders. Here's what you need to remember:

• POEM is a minimally invasive, incisionless procedure performed through the esophagus, offering rapid recovery and minimal pain 1 4 8.
• Effectiveness is high: 94–98% of patients experience sustained symptom relief, comparable to surgical approaches 6 7 8 9 10 15.
• Risks are low but present: Most adverse events are minor and manageable; GERD is a notable side effect, usually controlled with medication 8 9 11 12 13.
• Recovery is quick: Most patients return to normal activities within days, with careful dietary progression and routine follow-up 8 15.
• Alternatives exist: LHM is the main surgical alternative, while dilation and botulinum toxin offer less durable relief; investigational techniques may further improve outcomes 7 10 15 17 2.

In summary:

• POEM is a highly effective, minimally invasive therapy for achalasia and related disorders.
• It provides a safe, durable, and patient-friendly alternative to traditional surgery.
• The procedure's safety and efficacy are well-established in expert hands.
• Ongoing innovations and comparative studies continue to refine its role in esophageal disease management.

Always consult with an experienced gastroenterologist or surgeon to determine the best treatment strategy for your individual situation.